Name
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First Name
Last Name
1. Describe your relationship with your parents or caregivers in a few sentences.
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2. How many siblings do you have and what is your birth order?
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Are you the oldest, the middle, the youngest, only hild? If it's complicated, just try to briefly explain.
3. Who did you feel emotionally closest to growing up?
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My mother
My father
Both parents
Neither
My stepmother
My stepfather
A sibling or other relative
Someone outside the family
4. How were emotions expressed in your family?
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Choose the closest answer(s)
Openly shared and processed
Controlled or suppressed
Explosive or unpredictable
Avoided or intellectualized
5. What role did you feel you played in your family growing up?
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(Select all that apply)
Caregiver / Helper
Peacemaker / Mediator
Rebel / Troublemaker
Scapegoat
Golden Child
Invisible One
Overachiever / Performer
6. How would you describe your parents’ relationship with each other?
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7. Did you experience any of the following in your family system?
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(Select all that apply)
Parentification (you had to act like the adult)
Enmeshment (over-involvement without boundaries)
Emotional neglect
Abuse
Divorce / separation
Loss / grief
Addictions
Major mental illness
Spiritual pressure / religious guilt
None of the above
8. When you were upset as a child, how did your caregivers typically respond?
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Comforted you
Ignored or minimized your feelings
Punished or criticized you
Tried to fix the problem quickly
Unpredictable / inconsistent
8. Which of these did you feel you had to earn growing up?
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(Select all that apply)
Love
Approval
Belonging
Safety
Success
Attention
None of the above (I felt unconditionally supported and provided for)
9. How do you think your childhood affected your ability to ask for help today?
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10. Which unspoken family rules (or messages) shaped you most?
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(Choose up to 3)
Don’t Feel: “Emotions are dangerous, inconvenient, or shameful.” You learned to suppress sadness, anger, or even joy. Maybe emotions weren’t welcomed, or you were told to "stop crying" or "toughen up." You became emotionally numb or hyper-rational as a way to survive.
Don’t Fail: “Your worth depends on performance.” Perfection was expected. Mistakes were punished or met with disappointment. Success brought love or safety; failure brought shame. You became driven, anxious, or afraid to try new things.
Don’t Need: “Be self-sufficient at all costs.” You learned to minimize your needs, wants, or preferences. Asking for help felt weak or selfish. Maybe you parented yourself—or even your parents. You became independent to a fault, afraid to rely on others.
Always Help: “Your value lies in being useful to others.” Caretaking was expected, praised, or demanded. You put others’ needs before your own—sometimes chronically. Saying no felt like betrayal. You became the “responsible one” or “peacemaker,” but struggled with boundaries or burnout.
Don’t Speak: “Silence keeps the peace.” You were taught not to question authority, rock the boat, or name what’s wrong. Speaking up felt dangerous or pointless. You became quiet, diplomatic, or compliant—but often silenced your truth or opinions.
Don’t Be Weak: “Only the strong survive.” Vulnerability was seen as weakness. You were mocked for sensitivity or told to “man up.” You learned to be tough, stoic, or invulnerable—but at the cost of your softness or emotional connection.
Don’t Trust: “People will disappoint or betray you.” Maybe promises were broken, love was inconsistent, or you were let down often. You learned to rely only on yourself. You may now struggle to open up, delegate, or believe people mean well.
Be Perfect: “Flaws are not acceptable.” Image was everything—especially to outsiders. You learned to hide mess, suppress individuality, and be “on” all the time. Mistakes weren’t allowed. You became polished—but at war with your imperfections.
Keep the Peace: “Conflict is dangerous.” You were the peacemaker, the one who smoothed things over. Anger was avoided at all costs. You became hyper-attuned to others' moods, avoiding conflict and prioritizing harmony—even when it harmed you.
11. I feel most energized when I...
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Feel free and autonomous/independent
Feel competent and capable
Feel seen, loved, or connected
12. When I take action, it’s most often because...
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I genuinely want to
I feel like I should
I’m afraid of what will happen if I don’t
13. I’m most uncomfortable when I...
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Feel trapped or micromanaged
Feel like a failure
Feel emotionally disconnected
14. When I’m succeeding, I tend to...
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Downplay it
Feel like I must protect it
Fear others will expect more from me
Enjoy it and share the joy
15. Choose the statement that best describes you.
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I enjoy new ideas, abstract thinking, and creative exploration.
I prefer concrete facts, routines, and what is familiar.
16. Choose the statement that best describes you.
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I am organized, self-disciplined, and goal-oriented.
I tend to be more spontaneous, scattered, or flexible.
17. Choose the statement that best describes you.
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I am energized by social settings, action, and being around people.
I recharge best in solitude or with a few close relationships.
18. Choose the statement that best describes you.
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I tend to be cooperative, empathetic, and conflict-avoidant.
I am more skeptical, independent, and assertive.
19. Choose the statement that best describes you.
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I experience strong emotional reactions and stress easily.
I tend to be emotionally steady and resilient.
20. In a few words, describe a formative moment in childhood that still influences you today.