25. ______________ 55. ______________ Age: _____ Total=____________________________ 2 = extremely suspicious, possible homosexual ATTITUDES TOWARDS MOTHER tendency 14. ______________ 44. ______________ 1 = high ideas but ambivalent feelings. 29. ______________ 59. ______________ 0 = only minor or superficial criticisms Total=____________________________ X= Not Connected 2 = completely rejects and depreciates mother whom he considers ATTITUDE TOWARDS HETEROSEXUAL over demanding. RELATIONSHIP 1 = Sees mother’s fault but accepts and 11. ______________ 41. ______________ tolerates differences. 20. ______________ 56. ______________ 0 = express only positive feelings towards the Total=____________________________ mother. 2 = appears to have given up achieving good X= Not Connected sexual adjustment 1 = deserved sexual experiences but reservation ATTITUDES TOWARDS FATHER about his ability to 1. ______________ 31. ______________ maintain marital relationship. 16. ______________ 46. ______________ 0 = indicates satisfaction towards this area Total=____________________________ X= Not Connected 2 = feels extreme hostility and contempt with overt death wishes. ATTITUDE TOWARDS FRIENDS AND 1 = admires father but wishes that their ACQUAINTANCES relationship were closer. 8. ______________ 28. ______________ 0 = expresses complete satisfaction with father’s 23. ______________ 53. ______________ personality. Total=____________________________ X= Not Connected 2 = suspicious and apparently seclusive 1= seems to wait approval of others before ATTITUDE TOWARDS FAMILY UNIT committing himself 2. ______________ 42. ______________ emotionally 27. ______________ 57. ______________ 0 = express mutual relationship with friends and Total=____________________________ self 2 = feels rejected by the family which lacks X= Not Connected solidarity and which has constantly contended with difficulties. ATTITUDE TOWARDS PEOPLE 1 = aware that the family does not recognize SUPERVISED him as a mature person 4. ______________ 34. ______________ but has no difficulty in relating with them. 19. ______________ 58. ______________ 0 = instability of the family domicile has had Total=____________________________ little effect on his 2 = feels he can handle or control hostility in favorable feeling towards them. handling others X= Not Connected 1 = feels capable of doing good supervisory but 2 = concerned with spiritual feeling and physical has misgivings about sex drives assuming an authoritarian role. 1 = has regret over past and seems mildly 0 = feels controllable and well accepted by disturbed by his failure to subordinates. control his trouble. X= Not Connected 0 = does not seem to be aware of guilt feelings X= Not Connected ATTITUDE TOWARDS SUPERVISOR AT WORK OR SCHOOL ATTITUDE TOWARDS OWN ABILITY Total=____________________________ 2. ______________ 32_______________ 6. ______________ 36. ______________ 7. _____________ 47. ______________ 21. ______________ 51. ______________ Total=____________________________ 2 = resents or fear authority 2 = feels completely incompetent and hopeless 1 = mild difficulty in accepting difficulty 1 = feels he has a specific ability but tends to 0= fear difficulty X= Not Connected 0 = confident on his ability to overcome obstacles ATTITUDE TOWARDS COLLEAGUE AT WORK OR X= Not Connected SCHOOL 13. ______________ 43. ______________ ATTITUDES TOWARDS PAST 28. ______________ 58. ______________ 9. _____________ 39______________ Total=____________________________ 24. ______________ 54. ______________ 2 = feels rejected by colleagues, and condemns Total=____________________________ them 2 = feels rejected and isolated 1 = has some difficulty at work and depends on 1= colleagues 0 = feels well adjusted, no significant 0 = expresses good mutual feelings disturbance in the past X= Not Connected X= Not Connected
FEAR ATTITUDE TOWARDS THE FUTURE
7. ______________ 37.______________ 5. ______________ 35 ______________ 22. ______________ 52. ______________ 20. ______________ 50. ______________ Total=____________________________ Total=____________________________ 2 = disturbed by the apparent fear of loving, 2 = pessimistic, no hope in his own resources for possibility to control his Feelings happiness and success 1 = fear of self-assertion which is fairly common 1 = unsure of himself but tries to be optimistic and not pervasive. 0 = seems confident in achieving his goals 0 = lack of fear X= Not Connected X= Not Connected GOALS GUILT FEELINGS 3. ______________53. ______________ 15. ______________ 45. ______________ 18. ______________ 49. ______________ 30. ______________ 60. ______________ Total=____________________________ Total=____________________________ 2 = lack of motivation for achievement 1 = desires material things for family as well as for himself 0= X= Not Connected