Go&Dine Isolation Survey

Please indicate how often each of these statements below is descriptive of you. The answers given to this survey 

are COMPLETELY CONFIDENTIAL and will have no effect on your services going forward. The 

information gathered in this survey will only be used to determine whether the Go&Dine has had positive 

effects on those who use it.

1. I am unhappy doing so many things alone.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

2. I have nobody to talk to.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

3. I cannot tolerate being so alone.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

4. I lack companionship.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

5. I feel as if nobody really understands me.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

6. I find myself waiting for people to call or write.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

7. There is no one I can turn to.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

8. I am no longer close to anyone.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

9. My interests and ideas are not shared by those around me.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

10. I feel left out.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

11. I feel completely alone.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

12. I am unable to reach out and communicate with those around me.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

Turn Over

Russell, D. (1996). UCLA Loneliness Scale (Version 3): Reliability, validity and factor structure. Journal of 

Personality Assessment, 66, 20-40.

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Go&Dine Isolation Survey

13. My social relationships are superficial.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

14. I feel starved for company.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

15. No one really knows me well.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

16. I feel isolated from others.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

17. I am unhappy being so withdrawn.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

18. It is difficult for me to make friends.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

19. I feel shut out and excluded by others.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

20. People are around me but not with me.

$ I often feel this way. $ I sometimes feel this way. $ I rarely feel this way. $ I never feel this way.

Thank you for your feedback!

Official use only:

xxxx

$ Baseline $ 6 Months $ 12 Months

$ Erie $ Albany

Russell, D. (1996). UCLA Loneliness Scale (Version 3): Reliability, validity and factor structure. Journal of 

Personality Assessment, 66, 20-40.

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C 0 2

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