1. Do you envision a future of getting married and/or starting a family?
A. Only in my dreams, but I don’t think it will actually happen
B. I gave up on that dream a long time ago, but it would be nice
C. I do hope to find that someday
D. I don’t know. It’s not on the cards for me.
2. Has anyone ever told you that you are worthless, unattractive or that no one will ever be able to love you?
A. Yes, a few times
B. Not that I can recall
3. Do you feel like you come with too much baggage, and no one will want to take that on?
A. Not really
B. Many times, I do
C. I am not sure
D. Yes, definitely
4. Which of these is a fear you struggle with?
A. That no one will find you attractive or want to date you
B. That you are not a good person
C. That you don’t deserve true love
D. That you are unlovable
5. Have you ever had a serious relationship?
A. Only one, but it has been a while
B. Yes, several
C. Yes, but I feel like I have always been used in my relationships
6. How would you describe your childhood?
A. It was okay, but I often didn’t get any positive attention from people in my life
B. It wasn’t bad; I have good memories from childhood. It really isn’t about my childhood!
C. I was in trouble a lot or was criticized a lot by my parents
D. I had some traumatic experiences in my childhood
7. Have you ever felt genuine unconditional love from a friend, family member, or other adults in your life?
B. Yes, I have. But I am not sure if it’s genuine.
C. No, I have not
D. I don’t remember
8. Do you think you are attractive?
9. Which of these do you feel about yourself?
A. “Who would want to be with someone like me?”
B. “I am not a good person and don’t deserve a nice person who will treat me well.”
C. “No one will want to be with me once they get to truly know me.”
D. “No one would want to deal with someone like me who is broken and damaged.”
10. Have you ever hurt someone you loved?
A. No, not intentionally
B. Yes, many people
C. I am not sure
D. I don’t know if I have ever genuinely loved someone