First Name

Last Name

Email Address

Age

I spend about ______ of my time each day feeling irritated, frustrated, and angry. I spend about ______ of my time each day feeling irritated, frustrated, and angry. Not applicable 25% of the time 50% of the time 75% of the time Almost all of the time!

I feel emotionally close to my spouse. I feel emotionally close to my spouse. Yes No Sometimes Not as much as I'd like

I feel that I have experienced a sense of being unconditionally loved in my life. I feel that I have experienced a sense of being unconditionally loved in my life. Yes No Not sure

I treat my children with great love and respect. I treat my children with great love and respect. Always Sometimes Hardly ever; they drive me crazy!

I wonder if I made mistakes choosing the important relationships I have in my adult life. I wonder if I made mistakes choosing the important relationships I have in my adult life. Yes No Sometimes

I have experienced a lot of physical pain. I have experienced a lot of physical pain. Yes No Some

I feel that I am mostly: I feel that I am mostly: Relaxed and making conscious choices about my life Uptight and feeling drug around by the responsibilities I have Pretty good at saying no when needed Worried that I will let someone down

When my kids do something wrong, I: When my kids do something wrong, I: Get angry Want to run away Feel failed as a parent Get so frustrated I need time to calm down Assure them of my love while I teach them what they need to do differently next time

I know what my voice sounds like when I am kind and firm at the same time. I know what my voice sounds like when I am kind and firm at the same time. Yes! No, is that possible?

I have a loving relationship with my parents. I have a loving relationship with my parents. Yes No Mostly

I worry about how others are perceiving me, and I do my best to impress people I'm meeting for the first time. I worry about how others are perceiving me, and I do my best to impress people I'm meeting for the first time. Yes No Sometimes

Good grades were/are very important to me. Good grades were/are very important to me. Yes! No I wanted to learn and to do well, but I was ok with an occasional "B"

I recognize when I have been unloving toward my spouse and kids and I quickly take responsibility for my words and behaviors. I recognize when I have been unloving toward my spouse and kids and I quickly take responsibility for my words and behaviors. Mmm, sometimes Not usually Yes, I can clearly see myself and I practice honesty in my relationships

I have experienced multiple traumatic events in my lifetime. I have experienced multiple traumatic events in my lifetime. Yes No A few

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