Name *

First Name

Last Name

Phone

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1. How do you feel about your role within your family? *

A. I feel like I take on too much responsibility for everyone else.

B. I feel overlooked or unimportant in my family.

C. I feel like I’m always trying to mediate or keep the peace.

D. I’m comfortable with my role, but something still feels off.

2. Have there been significant traumas or losses in your family history (e.g., death, separation, financial loss)? *

A. Yes, and it has deeply affected our family.

B. Yes, but we don’t talk about it.

C. I’m not sure, but I feel the weight of something unresolved.

D. Not that I’m aware of.

3. Do you find yourself repeating patterns from your parents or grandparents (e.g., relationships, financial struggles, health issues)? *

A. Yes, I see the same patterns showing up in my life.

B. I see patterns, but I don’t fully understand them.

C. I try to avoid repeating the same mistakes, but it feels like a struggle.

D. I don’t notice any repeating patterns.

4. How do you feel about the level of connection within your family? *

A. We’re disconnected, and it causes tension.

B. There’s love, but we struggle to communicate.

C. I feel isolated or excluded from the family.

D. We have a strong bond, but there are unspoken issues.

5. When it comes to decision-making, do you find yourself influenced by your family’s expectations or opinions? *

A. Yes, I feel pressure to meet their expectations.

B. I try to make my own decisions, but I worry about what my family will think.

C. I find it hard to make decisions without considering my family’s opinions.

D. No, I feel confident in making decisions independently.