Age:_________ Sex:_________

Direction: Please read each of the following items carefully, thinking about how it relates to your life, and then indicate
how true it is for you. Use the following scale to respond:

1 2 3 4 5

Not at all true Somewhat A Moderate Quite a Bit Very True

True Amount True

1 2 3 4 5
1. I feel like I am free to decide for myself how to live my life.
2. I feel pressured in my life.
3. I generally feel free to express my ideas and opinions.
4. In my daily life, I frequently have to do what I am told.
5. People I interact with on a daily basis tend to take my
feelings into consideration.
6. I feel like I can pretty much be myself in my daily situations.
7. There is not much opportunity for me to decide for myself
how to do things in my daily life.

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Direction: Please respond to each item by filling in the number on a scale of 1 to 5 that best describes your
parents specifically your mother or your father. Please provide a single rating to describe your mother and
father and your relationship with them during childhood.

1 2 3 4 5

Not at All Somewhat A Moderate Amount Quite A Bit Very Much

(0-10%) (11-35%) (36-65%) (66-90%) (91-100%)

When I was young, my mother/father…. Mother Father

1. respects my privacy
2. restricts my freedom or independence
3. takes my opinions seriously
4. encourages me to make my own decisions
5. critical of what I can do
6. imposes his/her ideas and values on me
7. is a person to whom I can express differences of opinion on
important matters
8. has provided me with the freedom to experiment and learn
things on my own
9 has trust and confidence in me
10. tries to control my life
11. gives me advice whether or not I want it
12 respects my judgment and decisions, even if different from what
they would want.
13. does things for me, which I could do for myself
14. treats me like a baby