The following questionnaire is normally completed in conjunction with a consultation with Sharon or Dawson of FamilyWorks.

Question Title

* Please provide your contact info

Listed below are statements that people might use to describe themselves. Please read each statement, then rate it based on how accurately it fits you over the past year. When you are not sure, base your answer on what you emotionally feel, not on what you think to be true.

There are 90 short statements, which will probably take you about 20 minutes to complete. So make yourself comfortable and give fairly quick, instinctive responses :)


A few of the items ask about your relationships with your parents or romantic partners. If any of these people have died, please answer these items based on your relationships when they were alive. If you do not currently have a partner but have had partners in the past, please answer the item based on your most recent significant romantic partner.

Question Title

* Rate how accurately each of the following statements fits for you over the past year...

Completely untrue of me Mostly untrue of me Slightly more true than untrue Moderately true of me Mostly true of me Describes me perfectly
1. _____ I haven’t had someone to nurture me, share him/herself with me, or care deeply about everything that happens to me.
2. _____I find myself clinging to people I’m close to because I’m afraid they’ll leave me.
3. _____ I feel that people will take advantage of me.
4. _____ I don’t fit in.
5. _____ No man/woman I desire could love me once he or she saw my defects or flaws.
6. _____ Almost nothing I do at work (or school) is as good as other people can do.
7. _____ I do not feel capable of getting by on my own in everyday life.
8. _____ I can’t seem to escape the feeling that something bad is about to happen.
9. _____ I have not been able to separate myself from my parent(s) the way other people my age seem to.
10. _____ I think that if I do what I want, I’m only asking for trouble.
11. _____ I’m the one who usually ends up taking care of the people I’m close to.
12. _____ I am too self-conscious to show positive feelings to others (e.g., affection, showing I care).
13. _____ I must be the best at most of what I do; I can’t accept second best.
14. _____ I have a lot of trouble accepting “no” for an answer when I want something from other people.
15. _____ I can’t seem to discipline myself to complete most routine or boring tasks.
16. _____ Having money and knowing important people make me feel worthwhile.
17. _____ Even when things seem to be going well, I feel that it is only temporary.
18. _____ If I make a mistake, I deserve to be punished
19. _____ I don’t have people to give me warmth, holding, and affection.
20. _____ I need other people so much that I worry about losing them.
21. _____ I feel that I cannot let my guard down in the presence of other people, or else they will intentionally hurt me.
22. _____ I’m fundamentally different from other people.
23. _____ No one I desire would want to stay close to me if he or she knew the real me.
24. _____ I’m incompetent when it comes to achievement.
25. _____ I think of myself as a dependent person when it comes to everyday functioning.
26. _____ I feel that a disaster (natural, criminal, financial, or medical) could strike at any moment.
27. _____ My parent(s) and I tend to be over-involved in each other’s lives and problems.
28. _____ I feel as if I have no choice but to give in to other people’s wishes, or else they will retaliate, get angry, or reject me in some way.
29. _____ I am a good person because I think of others more than myself.
30. _____ I find it embarrassing to express my feelings to others.
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25% of survey complete.

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