This questionnaire asks you about your mother and father.  If you have more than one (1) mother and one (1) father, think about the mother and father to whom you feel closest.


M  

In the first column (marked M) I am thinking about my:

          1.  biological mother

          2.  stepmother 

          3.  adopted mother

          4.  foster mother  

          5.  other (please write-in)

          6.  I will not be answering this column because I don't have a mother.

F

In the second column (marked F) I am thinking about my:

          1.  biological father

          2.  stepfather

          3.  adopted  father

          4.  foster father

          5.  other (please write-in)

          6.  I will not be answering this column because I don't have a father.

 


 
1 2 3 4 5
 Not at All 
 (0-10%)
Somewhat
(11-35%) 
A Moderate Amount
(36-65%)
Quite A Bit
(66-90%)
Very Much
(91-100%)


In general, my mother/father.....
 

  M   F  

__  __  1.  is someone I can count on to listen to me when I feel upset.

__  __  2.  supports my goals and interests.

__  __  3.  sees the world differently than I do.

__  __  4.  understands my problems and concerns.

__  __  5.  respects my privacy.

__  __  6.  limits my independence.

__  __  7.  gives me advice when I ask for it.

__  __  8.  takes me seriously.

__  __  9.  likes me to make my own decisions.

__  __ 10. criticizes me.

__  __ 11. tells me what to think or how to feel.

__  __ 12. gives me attention when I want it.

__  __ 13.  is someone I can talk to about anything.

(go to next column)

 


 

  M   F

__  __  14.  has no idea what I am feeling or thinking.

__  __  15.  lets me try new things out and learn on my own.

__  __  16.  Is too busy to help me.

__  __  17.  Has trust and confidence in me.

__  __  18.  tries to control my life.

__  __  19.  protects me from danger and difficulty.

__  __  20.  ignores what I have to say.

__  __  21.  Is sensitive to my feelings and needs.

__  __  22.  Is disappointed in me.

__  __  23.  Gives me advice whether or not I want it.

__  __  24,  respect my decisions, even if they don't agree.

__  __  25.  does things for me which I would rather do for myself.

__  __  26.  Is someone whose expectations I feel I have to meet.

__  __  27.  treats me like a younger child.

(Go to next section)


1 2 3 4 5
 Not at All 
 (0-10%)
Somewhat
(11-35%) 
A Moderate Amount
(36-65%)
Quite A Bit
(66-90%)
Very Much
(91-100%)

During time spent together, my mother/father was someone...
 
 

  M   F  

__  __  28.  I looked forward to seeing

__  __  29.  with whom I argued.

__  __  30.  With whom I felt comfortable.

__  __  31.  who made me angry.

__  __  32.  I wanted to be with all the time.

__  __  33.  towards whom I felt cool and distant.

__  __  34.  Who got on my nerves.

(Go to next column)
 

  M   F  

__  __  35.  Who made me feel guilty and anxious.

__  __  36.  I liked telling about what I have done recently.

__  __  37.  for whom I felt feelings of love.

__  __  38.  I tried to ignore.

__  __  39.  to whom I told my most personal thoughts and feelings.

__  __  40.  I liked being with.

__  __  41.  I didn't want to tell what has been going on in in my life.

 



Following time spent together, I leave my mother/father...
 
 

  M   F    

__  __  42.  With warm and positive feelings.

(Go to next column)

  M   F

__  __  43.  feeling let down and disappointed.



When I have a serious problem or an important decision to make...
 
 

  M   F  

__  __  44.  I look to my family for help.  

__  __  45.  I go to a therapist, school counselor, or clergy (priest, rabbi or minister).  

__  __  46.  I think about what my mom or dad might say.

__  __  47.  I work it out on my own, without help from anyone.

(Go to next column)

  M   F   

__  __  48.  I talk it over with a friend.

__  __  49.  I know that my family will know what I should do.

__  __  50.  I ask my family for help if my friends can't  help.

 

 



When I go to my mother /father for help ...
 
 

  M   F

__  __  51.  I feel more sure of my ability to handle the problems on my own.

__  __  52.  I continue to feel unsure of myself.

__  __  53.  I feel that I would have gotten more understanding from a friend.

(Go to next column)
 

  M   F

__  __  54.  I feel sure that things will work out as long as I follow my parent's advice.

__  __  55.  I am disappointed with their response.