Name:

Email:

Q1. When someone pulls away from me emotionally, I usually:

Q2. I often worry that:

Q3. In conflict, I tend to:

Q4. In relationships, I usually feel:

Q5. When someone compliments me, I:

Q6. When I text someone and they don’t reply:

Q7. Growing up, my emotional needs were:

Q8. When someone wants to get close emotionally:

Q9. I feel most anxious in relationships when:

Q10. How do you usually respond to someone setting boundaries with you?

Q11. How do you show love?

Q12. How do you handle emotional intimacy?