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Running head: EFFECTS OF THERAPY

Survey Testing the Effects of Therapy on Self Esteem for Victims of Human Trafficking
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EFFECTS OF THERAPY
I. Demographics

1. What gender do you identify as? (Circle the letter that is most accurate.)

a. Male
b. Female
c. Other ____ (please indicate here)

2. What is your age?

a. Under 12 years old

b. 12-17 years old
c. 18-24 years old
d. 25-34 years old
e. 35-44 years old
f. 45-54 years old
g. 55-64 years old
h. 65-74 years old
i. 75 years or older

3. Please specify your ethnicity. (Circle the letter that is most accurate.)

a. Caucasian
b. African American
c. Latino or Hispanic
e. Native American
f. Native Hawaiian or Pacific Islander
g. Asian
h. Middle Eastern
i. Two or more
j. Prefer not to say

4. Are you currently married? (Circle the option that is most accurate.)

a. Yes
b. No

II. History of Therapy

1. Are you currently receiving therapy services? (Circle the option that is most accurate.)

a. Yes
b. No
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EFFECTS OF THERAPY
2. Have you been in therapy before? (Circle the option that is most accurate. Please circle yes if
you are currently receiving therapy services.)

a. Yes
b. No

3. Were you in therapy before or after your experience of being trafficked? (Circle the option
that is most accurate.)

a. Before
b. After
c. Both
d. I have never received therapy services

4. If yes to question 2, what has the modality been when receiving these services? (Circle the
option that is most accurate.)

a. Individual therapy
b. Group therapy
c. Both

5. If yes to question 2, what was the setting that you received or are receiving therapy services
in? (Circle the option that is most accurate.)

a. Clinical office
b. School
c. Home
d. Residential
c. Hospital
d. Other ____ (Please indicate.)

6. If yes to question 2, how long were you or have you been in therapy? (Circle the option that is
most accurate.)

a. Less than 1 year

b. 1 year
c. 2 years
d. 3 years
e. 4 years
f. 5+ years

III. Rosenberg Self-Esteem Scale (Rosenberg, 1965).

This 10-item scale measures global self-worth by measuring both positive and negative feelings
about the self. All items are answered using a 4-point Likert scale format ranging from strongly
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EFFECTS OF THERAPY
disagree to strongly agree. Below is a list of statements dealing with your general feelings about
yourself. Please indicate how strongly you agree or disagree with each statement by placing an
‘X’ or a check mark in the box to the right of each statement that best represents how you view
yourself.

Strongly Disagree Agree Strongly Agree

Disagree
1. I feel that I am
a person of
worth, at least on
an equal plane
with others.
2. I feel that I
have a number
of good
qualities.
3. All in all, I am
inclined to feel
that I am a
failure.
4. I am able to
do things as well
as most other
people.
5. I feel I do not
have much to be
proud of.
6. I take a
positive attitude
toward myself.
7. On the whole,
I am satisfied
with myself.
8. I wish I could
have more
respect for
myself.
9. I certainly feel
useless at times.
10. At times I
think I am no
good at all.
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