Name _____________________________ Date ____________________
Check the emotions you experienced: I feel that I am or have been:
Abused Boring Can’t do anything right Disrespected Failure Guilty Helpless Insignificant Incapable I should die I cause misery Neglected Not good enough Something is wrong with me Stupid Unacceptable Unwanted Unlovable Worthless
Check ways you have attempted to fix yourself or your circumstances:
Bible Study Counseling Church attendance Exercise New Job New Location New Relationships Put life in children or grand children People pleasing Performance Prayer Reading Work harder Vows
Check which of the following describe things you have done or do at your WORST or when you are depressed, angry, etc.
Alcohol Moody Seek attention Blame others Control Cheat Critical of self Critical of others Cry Drugs Eat Explode Fantasize Gamble Lie Manipulate Make excuses Read Reject others Romance Run/avoid Sex Spend $ StealTake no blame Take all the blame TV/Movies/Internet Try to fix Withdraw Worry Work harder
Check the characteristics which describe your spouse (or individuals) at their WORST, when you are at your worst. This person (s) is:
Abusive Against me Always right Angry Cheating on me Controlling Defensive Demanding Disappointed with me Emotional Explosive Harsh Hard to please Impersonal Incapable Inconsistent Inconsiderate Irrational Irresponsible Insecure Insensitive Manipulative Moody Quiet Trying to change me Selfish Rejecting me Unforgiving Has high expectations Unaffectionate Uncomplimentary Unkind Unloving Unrealistic Untrustworthy Withdrawn Will disappoint me
Other ___________
Circle yes or no on how you FEEL most of the time.
Yes or no: I prefer to work with things rather than people.
Yes or no: I internalize my frustration with others. I keep it to myself.
Yes or no: I’m often critical of myself.
Yes or no: People should keep the rules.
Yes or no: By the end of the day I feel tired.
Yes or no: People frustrate me.
Yes or no: I want others to invite me to events.
Yes or no: People are too inconsistent.
Yes or no: I do not like others inspecting my work/giving advice.
Yes or no: I want to know what will happen next.
Yes or no: I’m always thinking.
Yes or no: I enjoy being alone.
Yes or no: I find it difficult to fall asleep immediately.
Yes or no: I want lots of information on the outcome before I act.
Yes or no: I dislike change.
Yes or no: I think of myself as analytical.
Yes or no: I want to be in control.
Yes or no: I like a challenge.
Yes or no: Rules are frustrating.
Yes or no: People are lazy.
Yes or no: I like others to follow my plan.
Yes or no: I have lots of ideas most of the time.
Yes or no: I feel circumstances box me in.
Yes or no: People need to listen to me more.
Yes or no: Others lack the vision to help me accomplish my goals.
Yes or no: I prefer being the boss.
Yes or no: Problems challenge me.
Yes or no: Others often misunderstand me.
Yes or no: Others see me as harsh and uncaring.
Yes or no: When I get mad everyone knows it.
Yes or no: I like to see things happen immediately.
Yes or no: I hate routine.
Yes or no: I enjoy being with people.
Yes or no: I enjoy staying up late when I’m with others.
Yes or no: My feelings are easily hurt.
Yes or no: Hurting others bothers me.
Yes or no: I hate routine work.
Yes or no: I prefer to work with people and not be left alone.
Yes or no: I enjoy social activities.
Yes or no: I often feel that others do not like me.
Yes or no: I dislike being rejected.
Yes or no: I dislike being alone.
Yes or no: I like to motivate other people.
Yes or no: I cry easily.
Yes or no: I enjoy helping other people.
Yes or no: I like to include others in my projects.
Yes or no: I find myself easily influenced by others.
Yes or no: I like belonging to an organization. |
