5 Domains of Wellbeing Questionnaire

Safety

Do you feel safe in your home?
Yes No

Do you feel safe in your neighborhood?
Yes No

Do you feel safe at school?
Yes No

Have you ever been physically or sexually abused?
Yes No

Have you ever witnessed violence?
Yes No

Stability

Do you have a stable place to live?
Yes No

Do you have enough food to eat?
Yes No

Do you have access to healthcare?
Yes No

Do you have a supportive family?
Yes No

Do you have any close friends?
Yes No

Mastery

Do you feel like you are good at anything?
Yes No

Do you have any hobbies or interests that you enjoy?
Yes No

Do you feel like you are learning and growing?
Yes No

Do you feel like you have any control over your life?
Yes No

Do you feel like you can achieve your goals?
Yes No

Social Connectedness

Do you feel like you belong to any groups or communities?
Yes No

Do you feel like you have people you can rely on?
Yes No

Do you feel like you are making a difference in the world?
Yes No

Do you feel loved and accepted?
Yes No

Do you feel connected to something larger than yourself?
Yes No

Meaningful Access

Do you have access to education?
Yes No

Do you have access to employment opportunities?
Yes No

Do you have access to recreational activities?
Yes No

Do you have access to cultural activities?
Yes No

Do you have access to nature?
Yes No

Submit