Self-Discovery SuiteΔSELF-DISCOVERY SUITEFirst NameLast NameGender Female MaleDate of Birth (mm/dd)Year of Birth ReligionEmailPhoneProfessionBirth Order (E.g 1st out of Five, 2/5, 3/5, 5/5...)Residential AddressMarital Status Married Separated Divorced Engaged Dating Single ComplicatedWhat is your intention for this process?Section 1 - ATTACHMENT DYNAMICSChoose the response that best describes you from the following scale: Strongly Agree Agree Neutral Disagree Strongly Disagree1. I find it relatively easy to get emotionally close to others. Strongly Agree Agree Neutral Disagree Strongly Disagree2. I often worry about being abandoned or not loved by my partner. Strongly Agree Agree Neutral Disagree Strongly Disagree3. I find it difficult to fully trust others, even my partner. Strongly Agree Agree Neutral Disagree Strongly Disagree4. I feel conflicted about being close to others—I want connection but also fear it. Strongly Agree Agree Neutral Disagree Strongly Disagree5. I feel comfortable depending on others and having others depend on me. Strongly Agree Agree Neutral Disagree Strongly Disagree6. I feel insecure if my partner doesn’t immediately respond to me. Strongly Agree Agree Neutral Disagree Strongly Disagree7. I prefer not to rely on others and feel uncomfortable when they depend on me. Strongly Agree Agree Neutral Disagree Strongly Disagree8. I sometimes push people away even though I deeply want their attention. Strongly Agree Agree Neutral Disagree Strongly Disagree9. I am comfortable sharing my thoughts and feelings with my partner. Strongly Agree Agree Neutral Disagree Strongly Disagree10. I tend to crave a lot of reassurance and affection in my relationships. Strongly Agree Agree Neutral Disagree Strongly Disagree11. I often feel the need to keep emotional distance from others to feel safe. Strongly Agree Agree Neutral Disagree Strongly Disagree12. I experience sudden mood changes in relationships, going from feeling secure to scared or confused. Strongly Agree Agree Neutral Disagree Strongly Disagree13. I feel confident that my partner will support me when I need them. Strongly Agree Agree Neutral Disagree Strongly Disagree14. I sometimes feel that I am more invested in the relationship than my partner. Strongly Agree Agree Neutral Disagree Strongly Disagree15. I am uncomfortable with too much closeness and often push people away. Strongly Agree Agree Neutral Disagree Strongly Disagree16. I have difficulty trusting people and fear they will hurt or abandon me. Strongly Agree Agree Neutral Disagree Strongly Disagree17. I trust my relationships to be stable and secure, even when there’s temporary distance. Strongly Agree Agree Neutral Disagree Strongly Disagree18. I often feel anxious when my partner is not available, even for short periods. Strongly Agree Agree Neutral Disagree Strongly Disagree19. I value my independence and sometimes avoid sharing my feelings with my partner. Strongly Agree Agree Neutral Disagree Strongly Disagree20. I often feel overwhelmed by emotions and struggle to express them clearly in relationships. Strongly Agree Agree Neutral Disagree Strongly Disagree21. I am generally satisfied with the level of closeness in my relationships Strongly Agree Agree Neutral Disagree Strongly Disagree22. I fear that my partner might not care about me as much as I care about them. Strongly Agree Agree Neutral Disagree Strongly Disagree23. I find it challenging to be emotionally vulnerable, even with people I care about. Strongly Agree Agree Neutral Disagree Strongly Disagree24. I tend to experience intense emotional reactions when I feel rejected or ignored. Strongly Agree Agree Neutral Disagree Strongly DisagreeSection 2 - SELF-EMOTIONAL MAPPINGChoose the response that best describes you from the following scale: Rarely Sometimes Often Usually Always1. I am able to recognize when my emotions change, even subtly. Rarely Sometimes Often Usually Always2. I notice when my mood shifts, even if it’s for a small reason. Rarely Sometimes Often Usually Always3. When I feel overwhelmed, I can usually tell which specific emotion is causing it. Rarely Sometimes Often Usually Always4. I take a moment to identify my emotions before reacting. Rarely Sometimes Often Usually Always5. I am aware of my physical reactions (like heart rate or tension) as signals of my emotions. Rarely Sometimes Often Usually Always6. I understand how past experiences shape my emotional reactions. Rarely Sometimes Often Usually Always7. I am aware of specific situations or interactions that trigger strong emotions in me. Rarely Sometimes Often Usually Always8. I notice when I start feeling emotional tension before it escalates Rarely Sometimes Often Usually Always9. I recognize when a particular person or event triggers recurring emotional patterns. Rarely Sometimes Often Usually Always10. I can pinpoint situations that make me feel emotionally vulnerable or sensitive. Rarely Sometimes Often Usually Always11. I can calm myself down when I feel intense emotions. Rarely Sometimes Often Usually Always12. I avoid impulsive reactions when I’m experiencing strong emotions. Rarely Sometimes Often Usually Always13. I can manage my emotions in challenging situations without getting overwhelmed. Rarely Sometimes Often Usually Always14. I know when to take a break or step back to manage my emotions effectively. Rarely Sometimes Often Usually Always15. I can shift from negative emotions to more positive states with conscious effort. Rarely Sometimes Often Usually Always16. I recognize how my emotional state affects the way I behave with others. Rarely Sometimes Often Usually Always17. I understand how my emotions can affect my partner’s or friend’s mood. Rarely Sometimes Often Usually Always18. I am aware of how my emotional reactions might impact those around me. Rarely Sometimes Often Usually Always19. I can change my behavior if I realize my emotions are affecting others negatively. Rarely Sometimes Often Usually Always20. I consider how my emotions influence my decision-making. Rarely Sometimes Often Usually Always21. I reflect on my emotions to understand myself better. Rarely Sometimes Often Usually Always22. I recognize patterns in my emotional responses over time. Rarely Sometimes Often Usually Always23. I take responsibility for managing my emotions in relationships. Rarely Sometimes Often Usually Always24. I actively work on understanding the reasons behind my emotional triggers. Rarely Sometimes Often Usually Always25. I am committed to improving my emotional awareness and regulation skills. Rarely Sometimes Often Usually AlwaysSection 3 - PERSONALITY PROFILERead the list of statements and rate yourself from 0 - 10, with zero being the statement that least describes you and ten being the statement that most describes you.1. Many people think I am unemotional and blunt in relating with people and handling issues. 0 1 2 3 4 5 6 7 8 9 102. My work rate is high, able to work under pressure, taking risks or projects others think can’t be done. 0 1 2 3 4 5 6 7 8 9 103. I easily take the lead wherever I find myself and could get upset when goals are not met. 0 1 2 3 4 5 6 7 8 9 104. I usually ignore how people feel when I am chasing a goal or trying to get results. 0 1 2 3 4 5 6 7 8 9 105. I am very opinionated, and I can make decisions for others easily. 0 1 2 3 4 5 6 7 8 9 106. I love people and always want to make them happy. 0 1 2 3 4 5 6 7 8 9 107. I encourage people to work together and easily let go offences so we can move on 0 1 2 3 4 5 6 7 8 9 108. People notice me easily and love me because I am the life of the party wherever I find myself 0 1 2 3 4 5 6 7 8 9 109. I can motivate people to get things done. 0 1 2 3 4 5 6 7 8 9 1010. I dislike rules and regulations that promotes dogma & tradition because I know there are other ways to get the job done 0 1 2 3 4 5 6 7 8 9 1011. I naturally hate to offend people so I may be slow to confront issues because I am waiting for the right time to do it. 0 1 2 3 4 5 6 7 8 9 1012. People see me as a slow starter and they think I don’t like change but I am steady, dependable, controlled 0 1 2 3 4 5 6 7 8 9 1013. I love to work from the background without making noise about my accomplishment 0 1 2 3 4 5 6 7 8 9 1014. I withdraw from aggressive situations, would rather allow peace reign than be confrontational 0 1 2 3 4 5 6 7 8 9 1015. I am ambitious but I take my time and work at my pace 0 1 2 3 4 5 6 7 8 9 1016. I am a perfectionist to the core, I can’t stand disorganized people. 0 1 2 3 4 5 6 7 8 9 1017. I love to work based on rules and regulations and predetermined standards. 0 1 2 3 4 5 6 7 8 9 1018. I need time to think and plan before embarking on any project of journey. I rarely would jump on a trip or any venture without a proper plan and reflection 0 1 2 3 4 5 6 7 8 9 1019. I could be suspicious and critical of people, always weighing the intentions or motives behind whatever they do. 0 1 2 3 4 5 6 7 8 9 1020. I am very detailed and thorough in whatever I do, always trying to do things right leaving no room for error 0 1 2 3 4 5 6 7 8 9 10Section 4 - STRENGTH & GROWTH TRACKERChoose the response that best describes you using the following scale: 1 - Rarely 2 - Sometimes 3 - Often 4 - Usually 5 - Always1. I feel confident in the qualities I bring to my relationship. Rarely Sometimes Often Usually Always2. I am comfortable supporting my partner without expecting anything in return. Rarely Sometimes Often Usually Always3. I am a good listener, making others feel heard and understood. Rarely Sometimes Often Usually Always4. I manage to keep a positive attitude even during challenging times. Rarely Sometimes Often Usually Always5. I value honesty and transparency in my relationship. Rarely Sometimes Often Usually Always6. I actively seek feedback to understand how I can improve. Rarely Sometimes Often Usually Always7. I regularly reflect on my behaviors and how they impact my relationship. Rarely Sometimes Often Usually Always8. I am open to learning about myself, even if it reveals areas I need to work on. Rarely Sometimes Often Usually Always9. I recognize when I need to adjust my behaviors or attitudes. Rarely Sometimes Often Usually Always10. I am aware of both my strengths and weaknesses in my relationship. Rarely Sometimes Often Usually Always11. I communicate openly and clearly in my relationship. Rarely Sometimes Often Usually Always12. I stay calm and patient when conflicts arise. Rarely Sometimes Often Usually Always13. I am willing to compromise to reach a mutual understanding. Rarely Sometimes Often Usually Always14. I make an effort to resolve conflicts constructively. Rarely Sometimes Often Usually Always15. I am open to discussing difficult topics without becoming defensive. Rarely Sometimes Often Usually Always16. I can handle my emotions well, even in difficult situations. Rarely Sometimes Often Usually Always17. I recover quickly from setbacks and learn from challenges. Rarely Sometimes Often Usually Always18. I stay focused and calm under pressure. Rarely Sometimes Often Usually Always19. I avoid taking out my frustrations on my partner. Rarely Sometimes Often Usually Always20. I work on improving my emotional stability for my personal growth. Rarely Sometimes Often Usually Always21. I am willing to try new things that might improve my relationship. Rarely Sometimes Often Usually Always22. I view challenges as opportunities to grow and learn. Rarely Sometimes Often Usually Always23. I adapt my behaviors based on feedback from my partner. Rarely Sometimes Often Usually Always24. I actively seek ways to improve myself and my relationship. Rarely Sometimes Often Usually Always25. I am committed to ongoing personal development and growth. Rarely Sometimes Often Usually AlwaysSection 5 - TRAUMA IMPACT Answer each statement honestly based on your feelings and experiences. • Use the scale provided to indicate how strongly you agree or disagree with each statement. Strongly Disagree Disagree Neutral Agree Strongly Agree 1. I have experienced physical abuse in my life. Strongly Disagree Disagree Neutral Agree Strongly Agree2. I have experienced emotional or psychological abuse in my life. Strongly Disagree Disagree Neutral Agree Strongly Agree3. I have experienced sexual abuse or assault. Strongly Disagree Disagree Neutral Agree Strongly Agree4. I have experienced neglect or abandonment. Strongly Disagree Disagree Neutral Agree Strongly Agree5. I have experienced a significant loss (e.g., death of a loved one). Strongly Disagree Disagree Neutral Agree Strongly Agree6. I have experienced a traumatic accident or injury. Strongly Disagree Disagree Neutral Agree Strongly Agree7. I have witnessed violence or traumatic events. Strongly Disagree Disagree Neutral Agree Strongly Agree8. I have experienced a natural disaster (e.g., earthquake, flood). Strongly Disagree Disagree Neutral Agree Strongly Agree9. I have experienced chronic illness or severe health issues. Strongly Disagree Disagree Neutral Agree Strongly Agree10. I have experienced other forms of trauma not listed above. Strongly Disagree Disagree Neutral Agree Strongly Agree11. I often feel anxious or fearful without a clear reason. Strongly Disagree Disagree Neutral Agree Strongly Agree12. I have frequent nightmares or flashbacks about past events. Strongly Disagree Disagree Neutral Agree Strongly Agree13. I find it difficult to trust others. Strongly Disagree Disagree Neutral Agree Strongly Agree14. I often feel emotionally numb or detached. Strongly Disagree Disagree Neutral Agree Strongly Agree15. I have difficulty managing my anger or emotions. Strongly Disagree Disagree Neutral Agree Strongly Agree16. I experience feelings of shame or guilt related to past events. Strongly Disagree Disagree Neutral Agree Strongly Agree17. I often feel overwhelmed or unable to cope with stress. Strongly Disagree Disagree Neutral Agree Strongly Agree18. I avoid people, places, or activities that remind me of past trauma. Strongly Disagree Disagree Neutral Agree Strongly Agree19. I have difficulty forming or maintaining relationships. Strongly Disagree Disagree Neutral Agree Strongly Agree20. I struggle with feelings of depression or hopelessness. Strongly Disagree Disagree Neutral Agree Strongly Agree21. I experience frequent headaches or migraines. Strongly Disagree Disagree Neutral Agree Strongly Agree22. I have chronic pain or physical discomfort. Strongly Disagree Disagree Neutral Agree Strongly Agree23. I have trouble sleeping or experience insomnia. Strongly Disagree Disagree Neutral Agree Strongly Agree24. I often feel fatigued or lacking in energy. Strongly Disagree Disagree Neutral Agree Strongly Agree25. I experience gastrointestinal issues (e.g., stomach aches, nausea). Strongly Disagree Disagree Neutral Agree Strongly Agree26. I have difficulty breathing or experience shortness of breath. Strongly Disagree Disagree Neutral Agree Strongly Agree27. I have a weakened immune system or frequent illnesses Strongly Disagree Disagree Neutral Agree Strongly Agree28. I engage in self-destructive behaviors (e.g., substance abuse, self-harm). Strongly Disagree Disagree Neutral Agree Strongly Agree29. I have an eating disorder or disordered eating patterns. Strongly Disagree Disagree Neutral Agree Strongly Agree30. I experience other physical symptoms not listed above that may be related to stress or trauma. Strongly Disagree Disagree Neutral Agree Strongly Agree31. I have trouble concentrating or staying focused. Strongly Disagree Disagree Neutral Agree Strongly Agree32. I experience memory problems or difficulty recalling information. Strongly Disagree Disagree Neutral Agree Strongly Agree33. I often feel confused or disoriented. Strongly Disagree Disagree Neutral Agree Strongly Agree34. I have negative thoughts or beliefs about myself. Strongly Disagree Disagree Neutral Agree Strongly Agree35. I struggle with decision-making or problem-solving. Strongly Disagree Disagree Neutral Agree Strongly Agree36. I feel easily overwhelmed by everyday tasks. Strongly Disagree Disagree Neutral Agree Strongly Agree37. I have intrusive thoughts about past traumatic events. Strongly Disagree Disagree Neutral Agree Strongly Agree38. I have a negative outlook on the future. Strongly Disagree Disagree Neutral Agree Strongly Agree39. I often feel disconnected from reality. Strongly Disagree Disagree Neutral Agree Strongly Agree40. I experience other cognitive difficulties not listed above. Strongly Disagree Disagree Neutral Agree Strongly AgreeSubmit Form
