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Attachment Questionnaiie

Siegel, Baniel }., & Baitzell, Nai. (2uu4). !"#$%&'%( *#+, &-$ .%/'0$ 12&3 4+5 " 6$$7$# 8$9*:;%0$#/&"%0'%(
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Name ______________________________________ Bate ______________________________

Please use auuitional papei to answei these questions so youi iesponses will not be limiteu.

1. What was it like giowing up. Who was in youi family.

2. Bow uiu you get along with youi paients eaily in youi chiluhoou. Bow uiu the ielationship
evolve thioughout youi youth anu up until the piesent time.

S. Bow uiu youi ielationship with youi mothei anu fathei uiffei anu how weie they similai.
Aie theie ways in which you tiy to be like, oi tiy not to be like, each of youi paients.

4. Biu you evei feel iejecteu oi thieateneu by youi paients. Weie theie othei expeiiences you
hau that felt oveiwhelming oi tiaumatizing in youi life, uuiing chiluhoou oi beyonu. Bo any of
these expeiiences still feel veiy much alive. Bo they continue to influence youi life.

S. Bow uiu youi paients uiscipline you as a chilu. What impact uiu they have on youi
chiluhoou, anu how uo you feel it affects youi iole as a paient now.

6. Bo you iecall youi eailiest sepaiations fiom youi paients. What was it like. Biu you evei
have piolongeu sepaiations fiom youi paients.

7. Biu anyone significant in youi life uie uuiing youi chiluhoou, oi latei in youi life. What was
that like foi you at the time, anu how uoes that loss affect you now.

8. Bow uiu youi paients communicate with you when you weie happy anu exciteu. Biu they
join with you in youi enthusiasm. When you weie uistiesseu oi unhappy as a chilu, what woulu
happen. Biu youi fathei anu mothei iesponu uiffeiently to you uuiing these emotional times.

9. Was theie anyone else besiues youi paients in youi chiluhoou who took caie of you. What
was that ielationship like foi you. What happeneu to these inuiviuuals. What is it like foi you
when you let otheis take caie of youi chilu now.

Attachment Questionnaiie
Paienting fiom the Insiue 0ut
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1u. If you hau uifficult times uuiing youi chiluhoou, wheie theie positive ielationships in oi
outsiue youi home that you coulu uepenu on uuiing those times. Bow uo you feel those
connections benefiteu you then, anu how might they help you now.

11. Bow have youi chiluhoou expeiiences influenceu youi ielationships with otheis as an auult.
Bo you finu youiself tiying not to behave in ceitain ways because of what happeneu to you as a
chilu. Bo you have patteins of behaviois that you'u like to altei but have uifficulty changing.

12. What impact uo you think youi chiluhoou has hau on youi auult life in geneial, incluuing the
ways in which you think of youiself anu the ways you ielate to youi chiluien. What woulu you
like to change about the way you unueistanu youiself anu ielate to otheis.