SELF-ASSESSMENT QUESTIONNAIRE

BONDING STAGE  (Birth to 6-9 months)

                                                    NEVER      SELDOM         SOMETIMES            OFTEN              ALWAYS

1. I know when my body needs something (food, air, water, rest, etc).     
                

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1. I know when my body needs something (food, air, water, rest, etc).     
              

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3. I know when I need strokes.  

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4. I am comfortable in new situations.      
              

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5. I can try out new things without getting in trouble or hurting myself. 
           

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6. I am comfortable selecting what I like and don't like in new situations.
            

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7. I can enjoy myself by exploring something new.   

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                                                    NEVER      SELDOM         SOMETIMES            OFTEN              ALWAYS

8. I feel independent and autonomous.                   
 

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9. When I make decisions, I count myself and others equally.
                      

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10. I am comfortable sharing my ideas and opinions with others who have ideas of their own, even if their ideas differ from mine.   
    

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11. I am comfortable about the ways in which I am different from others. 
       

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12. I am comfortable about the ways in which I am similar to others.  
          

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13. I am able to be vocal and stubborn in opposing things I think are destructive.   

                

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14. I am comfortable asking questions when I don’t understand or want to know something.
               

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15. I can recognize and acknowledge other people's feelings.                  

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16. I have the ability to find out what others feel when I don't know.            

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17. I can confront others when I see problems in what they are doing, saying, or feeling.   

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18. I can tell when to give up on something that isn't working.   
                   

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19. I am willing to feel sadness and grief when I have to let go of something that was important to me.           

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                                                    NEVER      SELDOM         SOMETIMES            OFTEN              ALWAYS

20. I am comfortable learning how to do new things that I didn't know how to do before.  

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21. I do things as well as they need to be done.   

       

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22. I finish things that need to be finished.         
      

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23. I can recognize and communicate about the reasons for my values and beliefs.
      

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24. I can recognize and understand that others have different reasons for their values and beliefs.   
                   

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25. I am comfortable negotiating openly with others to satisfy our needs and wants.     

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26. I recognize and am comfortable with the fact that I am connected to other people. 
 

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27. I can be interdependent with others without sacrificing my own autonomy.                

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(From An Action Plan for Your Inner Child: Parenting Each Other by Laurie Weiss, Ph.D. Deerfield Beach, Florida:  Health Communications, 1991.)