Questionnaire
C. Please Tell Us About Your Family of Origin.
For many of the questions that follow
you will answer by circling a number on a scale from 1 to 7:
|
I = Strongly Disagree
|
5 = Slightly Agree |
2 = Disagree
|
6 = Agree |
2 = Disagree
|
6 = Agree |
|
3 = Slightly Disagree
|
7 = Strongly Agree |
| 4 = Equally Agree and Disagree |
0 = Not Applicable to my Experience (NA)
|
The questions in this section are about your growing up years.
Mother and Father refer to the "parent(s)" who raised you.
Circle "0" to mean "no mother figure" or "no father figure."
While I was growing up (circle the best answer for each statement):
-
My mother and father openly demonstrated physical affection
for each other.
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
a. My father affectionately touched (for example, hugged) me.
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
b. This affection was appropriately expressed.
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
a. My mother affectionately touched me.
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
b. This affection was appropriately expressed.
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
I felt free to express my own opinions at home.
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
Sexuality was often discussed in my family.
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
a. My mother's attitude toward sex was generally positive.
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
b. My father's attitude toward sex was generally positive
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
< Previous Next >
Remember
The questionnaire is here for VIEWING ONLY.
Please DO NOT send your answers to me.
Copyright 1998, Carol Ellison, Ph.D.
