Name - Date - : Instructions
Name - Date - : Instructions
Name - Date - : Instructions
Name_____________________________Date_____________
INSTRUCTIONS:
Listed below are statements that you might use to describe your
parents. Please read each statement and decide how well it
describes your parents. Choose the highest rating from 1 to 6
that describes your mother, then your father, when you were a
child and write the number in the spaces before each statement.
If someone substituted as your mother or father, please rate the
scale for that person. If you did not have a mother or a father,
leave the appropriate column blank.
RATING SCALE:
1
2
3
4
5
6
MOTHER
FATHER
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=
=
=
=
=
=
Completely untrue
Mostly untrue
Slightly more true than untrue
Moderately true
Mostly true
Describes him/her perfectly
DESCRIPTION
1.
2.
3.
4.
5.
*ed
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6.
7.
8.
9.
*ab
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10.
11.
12.
13.
*ma
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14.
15.
16.
17.
*vh
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21.
22.
23.
24.
Criticized me a lot.
Made me feel unloved or rejected.
Treated me as if there was something wrong with me.
Made me feel ashamed of myself in important respects.
*ds
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25.
26.
27.
28.
*fa
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29.
30.
31.
32.
*sb
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33.
34.
35.
36.
*ss
37.
38.
39.
40.
41.
42.
43.
*us
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44.
45.
46.
47.
*et
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48.
49.
50.
51.
*is
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56.
57.
58.
59.
*np
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60.
61.
62.
63.
64.
*ei
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65.
66.
67.
68.
*pu
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69.
70.
71.
72.
*as