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RELATIONAL HISTORY & ASSESSMENT QUESTIONNAIRE

This questionnaire is designed to provide background information about your experiences, relationships, and personal history. There are no right or wrong answers. Please answer as accurately as possible based on your experience.

SECTION 1 OF 5

What was your position among your siblings?
Only child
Oldest child
Middle child
Youngest child
Twin
How many children were raised in your household (including yourself)?
1
2
3
4
5+
Which adults played a significant caregiving role during your childhood? (Select all that apply)
Mother
Father
Grandparent(s)
Step-parent
Older sibling
Other relative
Non-family caregiver
During most of your childhood, your parents or primary caregivers were:
Together
Separated
Divorced
One parent absent
Other
In your family, emotions were generally:
Encouraged and discussed
Acknowledged but rarely discussed
Handled privately
Often avoided
Unpredictably expressed
Frequently criticized
When conflict occurred, people most often:
Which best describes the emotional atmosphere of your home growing up? (Select up to 5)
Conflict in your family was generally:
Rare
Occasional
Frequent
Constant

© 2026 Farshid Rashidifar. All rights reserved.  

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