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Toxicity Assessment Survey for Family, Places, or Situations
Evaluating the Atmosphere
“A reflective tool for family Dynamics and Spaces”
*
1.
How often do you feel stressed or anxious when interacting with your family?
(Required.)
Never
Rarely
Sometimes
Often
Always
*
2.
Do you feel respected and valued by your family members?
(Required.)
Always
Most of the time
Sometimes
Rarely
Never
*
3.
How often do conflicts or arguments occur in your family?
(Required.)
Never
Rarely
Sometimes
Often
Always
*
4.
Do you feel emotionally safe and supported in your family?
(Required.)
Always
Most of the time
Sometimes
Rarely
Never
*
5.
Which of the following behaviors have you experienced from your family members? Select all that apply
(Required.)
Criticism
Manipulation
Neglect
Abuse (emotional, physical, or verbal)
Gaslighting
None of the above
*
6.
How often do you feel drained or exhausted after spending time with your family?
(Required.)
Never
Rarely
Sometimes
Often
Always
*
7.
Do you feel you can be yourself around your family without fear of judgment or criticism?
(Required.)
Always
Most of the time
Sometimes
Rarely
Never
*
8.
How often do you feel your family respects your boundaries?
(Required.)
Always
Most of the time
Sometimes
Rarely
Never
*
9.
Do you feel that your family dynamic is negatively impacting your mental health?
(Required.)
Yes
No
Not sure
*
10.
Have you considered estrangement from your family?
(Required.)
Yes
No
Not sure