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Name
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Email Address
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How would you like us to deliver your results? (You can choose options you are cool with)
Call
Text
Whatsapp
Email
We recommend Call (Direct/via whatsapp) so that your assigned psychotherapist can directly brief you on your results and offer personalized recommendations based on your submission. You would be sent a reminder text/email when your results are ready (usually within 60 minutes), then schedule an available time for your assigned psychotherapist call. We will not charge you for this call. Thank you very much.
General Family Satisfaction
How satisfied are you with the current dynamics within your family?
Very satisfied
Somewhat satisfied
Neutral
Dissatisfied
Very dissatisfied
How often do you experience stress or frustration in family interactions?
Rarely
Occasionally
Frequently
Almost Always
Communication within the Family
How effective is communication within your family?
Very effective, we communicate openly
Somewhat effective, but with challenges
Poor, we struggle to communicate clearly
Very poor, communication is often tense or avoided
Do you feel your opinions and feelings are respected by family members?
Always
Sometimes
Rarely
Never
When conflicts arise, how are they usually handled within your family?
We resolve them calmly and quickly
It takes time, but they are resolved
Conflicts are often ignored or remain unresolved
Conflicts often escalate and lead to arguments
Sources of Stress and Resentment
What are the common sources of stress or resentment in your family? (Select all that apply)
Financial issues
Lack of communication
Differences in values or lifestyle choices
Past unresolved conflicts
Parenting or caregiving responsibilities
other
How often do you feel unsupported or misunderstood by family members?
Rarely
Occasionally
Frequently
Almost Always
How do disagreements within your family typically make you feel?
Frustrated
Angry
Disconnected
Resentful
other
Emotional Connection and Support
Do you feel emotionally connected to your family?
Yes, always
Yes, but only with certain family members
No, not often
No, not at all
How often do you feel comfortable sharing your personal challenges or emotional struggles with your family?
Always
Sometimes
Rarely
Never
Do you feel your family members offer emotional support when needed?
Yes, always
Sometimes
Rarely
No, I don’t feel supported
Family Conflict and Resolution
How often do conflicts in your family escalate into long-term issues?
Almost never
Sometimes
Frequently
Almost always
When conflicts are resolved, how satisfied are you with the outcome?
Very satisfied
Somewhat satisfied
Dissatisfied
Conflicts are rarely resolved
Do you feel that past conflicts or unresolved issues impact your current family relationships?
No, they don’t have an impact
Yes, but only occasionally
Yes, frequently
Yes, almost always
Improvement and Emotional Healing
Would you be open to family therapy or counseling to address ongoing conflicts or emotional pain?
Yes, I’m open and willing
Maybe, but I’m unsure
No, I don’t think we need it
What areas in your family relationships would you like to see improve the most?
Communication
Emotional support
Trust and understanding
Conflict resolution
Time spent together
other
Emotional Summary
Which emotions best describe your experience in family relationships? (Choose all that apply)
Stress
Anger
Resentment
Loneliness
Love and support
Hopelessness
Frustration
other
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