Toxicity Assessment Survey for Family, Places, or Situations

Evaluating the Atmosphere

“A reflective tool for family Dynamics and Spaces”

Question Title

* 1. How often do you feel stressed or anxious when interacting with your family?

Never

Rarely

Sometimes

Often

Always

Question Title

* 2. Do you feel respected and valued by your family members?

Always

Most of the time

Sometimes

Rarely

Never

Question Title

* 3. How often do conflicts or arguments occur in your family?

Never

Rarely

Sometimes

Often

Always

Question Title

* 4. Do you feel emotionally safe and supported in your family?

Always

Most of the time

Sometimes

Rarely

Never

Question Title

* 5. Which of the following behaviors have you experienced from your family members? Select all that apply

Criticism

Manipulation

Neglect

Abuse (emotional, physical, or verbal)

Gaslighting

None of the above

Question Title

* 6. How often do you feel drained or exhausted after spending time with your family?

Never

Rarely

Sometimes

Often

Always

Question Title

* 7. Do you feel you can be yourself around your family without fear of judgment or criticism?

Always

Most of the time

Sometimes

Rarely

Never

Question Title

* 8. How often do you feel your family respects your boundaries?

Always

Most of the time

Sometimes

Rarely

Never

Question Title

* 9. Do you feel that your family dynamic is negatively impacting your mental health?

Yes

Not sure

Question Title

* 10. Have you considered estrangement from your family?

Yes

Not sure