First Name

Last Name

Email Address

Directions

This scale is designed to measure some of the emotions that existed in the family in which you were raised and currently exists in one of your other relationships. Please answer the first half of the form as regarding your family of origin and the second half of the form as it relates to your current spouse. Since each person and family is unique, there is no right or wrong answers. Just try to respond as honestly as you can. Please respond to every statement.

Rate the following statements as they apply to the family and parent(s) with whom you spent most of your childhood.

In reading the following statements, apply them to yourself and your family and then select the rating that best fits.

I could trust my family to seek my best interests.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

Individuals in my family were blamed for problems that were not their fault.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

Pleasing one of my parents often meant displeasing the other.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

I received the love and affection from my family that I deserved.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

No matter what happened, I always stood by my family.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

At times, it seemed like one or both of my parents disliked me.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

Love and warmth were given equally to all family members.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

At times, I was used by my family unfairly.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

I felt like my life was dominated by my parents desires.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

Individuals in my family were willing to give of themselves to benefit the family.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

I continue to seek a closer relationship with my family.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

I often felt deserted by my family.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

I try to meet the emotional needs of this person
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

I do not trust this individual to look out for my best interests.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

When I feel hurt, I say or do hurtful things to this person.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

This person stands beside me in times of trouble or joy.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

Before I make important decisions, I ask for the opinions of this person.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

There is unequal contribution to the relationship between me and this individual.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

When I feel angry, I tend to take it out on this person.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

We are equal partners in this relationship.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

We give of ourselves to benefit one another.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

I take advantage of this individual.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

I am taken for granted or used unfairly in this relationship.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

This person listens to me and values my thoughts.
1 - Strongly Disagree2 - Disagree3 - Neither Agree nor Disagree4 - Agree5 - Strongly Agree

Δ