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  1. Surveys
  2. 2013
  3. January
  4. B
  5. borderline personality attachment
0%
Exit Survey
 
 
How old is the child?
   
 
 
 
What gender is the child?
 
Male
 
Female
 
Other
 
 
 
 
What is your relationship to the child?
 
Biological parent
 
Adoptive parent
 
Foster parent
 
Stepparent
 
Other
 
 
 
 
Do you currently have custody of the child?
 
Yes
 
No
 
Other
 
 
 
 
What diagnoses does the child have?
   
 
 
 
In what country do you live?
   
 
 
 
How many times has your child lost a caregiver or gained a new one? (Eg parent dying or losing custody, moving to new foster home, etc)
 
Never
 
Once
 
Twice
 
Three times
 
Four or more times
 
 
 
 
Is there any one person who has been in your child's life the whole time? If so, who?
   
 
 
 
If your child has lost one of more caregivers, at what ages?
 
Less than 1 year
 
1-5 years
 
6-10 years
 
11-15 years
 
15-18 years
 
Don't know

 
 
How well do these statements describe your child?
Not at all Slightly Partially Strongly Completely N/A
Emotions tend to spiral out of control, leading to extremes of anxiety, sadness, rage, excitement, etc.
Tends to get into power struggles with adults.
Psychological issues interfere with appropriate functioning at school (or work, if s/he is no longer in school).
Lacks a stable image of who s/he is (e.g., attitudes, values, goals, and feelings about self are highly unstable).
Tends to feel misunderstood, mistreated, or victimized.
Tends to be angry or hostile (whether consciously or unconsciously).
Tends to feel unhappy, depressed, or despondent.
Tends to fear s/he will be rejected or abandoned by those who are emotionally significant.
Is unable to soothe or comfort self when distressed; requires involvement of another person to help regulate affect.
Tends to be rebellious or defiant toward authority.
Not at all Slightly Partially Strongly Completely N/A
Tends to react to criticism with feelings of rage or humiliation.
Tends to elicit extreme reactions or stir up strong feelings in others.
Tends to express intense and inappropriate anger, out of proportion to the situation at hand.
Tends to be oppositional, contrary, or quick to disagree.
Emotions tend to change rapidly and unpredictably.
Tends to be critical of others.
Tends to blame others for own failures or shortcomings; tends to believe his/her problems are caused by external factors.
Tends to act impulsively, without regard for consequences.
Expresses emotion in exaggerated and theatrical ways.
Tends to feel s/he is inadequate, inferior, or a failure.
Not at all Slightly Partially Strongly Completely N/A
Manages to elicit in others feelings similar to those he or she is experiencing (e.g., when angry, acts in such a way as to provoke anger in others; when anxious, acts in such a way as to induce anxiety in
 
others).
Tends to feel empty.
Tends to become irrational when strong emotions are stirred up; may show a noticeable decline from customary level of functioning.
Appears inhibited about pursuing goals or successes; aspirations or achievements tend to be below his/her potential.
Tends to feel bored.
Tends to be unreliable and irresponsible (e.g., may fail to meet school or work obligations).
Tends to use his/her psychological or medical problems to avoid school, work, or responsibility (whether consciously or unconsciously).
Appears to gain pleasure or satisfaction by being sadistic, aggressive, or a bully (whether consciously or unconsciously).
Not at all Slightly Partially Strongly Completely N/A
Tends to get drawn into relationships (outside of his/her own family) in which s/he is emotionally or physically abused.
Has an exaggerated sense of self-importance; tends to boast or brag.
Tends to choose sexual or romantic partners who seem inappropriate in terms of age, status (e.g., social, economic, intellectual), etc.
Tends to show reckless disregard for the rights, property, or safety of others.
Tends to see self as logical and rational, uninfluenced by emotion; prefers to operate as if emotions were irrelevant or inconsequential.
Takes advantage of others; is out for number one; has minimal investment in moral values.
Has trouble making decisions; tends to be indecisive or to vacillate when faced with choices.
Seeks to dominate an important other (e.g., sibling, boyfriend, girlfriend, parent) through violence or intimidation.
Tends to be overly sexually seductive or provocative (e.g., may be inappropriately flirtatious).
Appears to experience no remorse for harm or injury caused to others.
Not at all Slightly Partially Strongly Completely N/A
Tends to make repeated suicidal threats or gestures, either as a ‘cry for help’ or as an effort to manipulate others.
Appears to have little need for human company or contact; is genuinely indifferent to the presence of others.
Has uncontrolled eating binges followed by ‘purges’ (e.g., makes self vomit, abuses laxatives, fasts, etc.); has bulimic episodes.
Tends to be preoccupied with food, diet, or eating.
Promises to change but then reverts to previous maladaptive behavior; gets other people to believe that ‘this time is really different.'
Is articulate; can express self well in words.
Appreciates and responds to humor.
Tends to express intense and inappropriate anger, out of proportion to the situation at hand.
Tries to manipulate others’ emotions to get what s/he wants.
Tends to be self-critical; sets unrealistically high standards for self and is intolerant of own human defects.
Not at all Slightly Partially Strongly Completely N/A
Tends to elicit liking in others.
Has moral and ethical standards and strives to live up to them.
Tends to be anxious.
Tends to blame self or feel responsible for bad things that happen.
Tends to feel guilty.
Tends to be conscientious and responsible.
Appears to want to ‘punish’ self; creates situations that lead to unhappiness, or actively avoids opportunities for pleasure and gratification.
Tends to feel s/he is not his/her true self with others; tends to feel false or fraudulent.
Is creative; is able to see things or approach problems in novel ways.
Is psychologically insightful; is able to understand self and others in subtle and sophisticated ways.
Not at all Slightly Partially Strongly Completely N/A
Tends to oscillate between undercontrol and overcontrol of needs and impulses.
Tends to become attached quickly or intensely; develops feelings, expectations, etc. that are not warranted by the history or context of the relationship.
Interpersonal relationships tend to be unstable, chaotic, and rapidly changing.
Seeks to be the center of attention.
Fantasizes about finding ideal, perfect love.
Tends to use his/her physical attractiveness to an excessive degree to gain attention or notice.
Tends to idealize certain others in unrealistic ways; sees them as ‘all good,’ to the exclusion of commonplace human defects.
Is quick to assume that others wish to harm or take advantage of him/her; tends to perceive malevolent intentions in others’ words and actions.
Is simultaneously needy of, and rejecting toward, others (e.g., craves intimacy and caring, but tends to reject it when offered).
Has little psychological insight into own motives, behavior, etc.; is unable to consider alternate interpretations of his/her experiences.
Not at all Slightly Partially Strongly Completely N/A
Tends to feel life has no meaning.
Appears to find little or no pleasure, satisfaction, or enjoyment in life’s activities.
Tends to feel like an outcast or outsider; feels as if s/he does not truly belong.
Tends to get ignored, neglected, or avoided by peers.
Is easily frustrated (e.g. gives up quickly).
Tends to surround self with peers who are delinquent or deeply alienated.
Tends to see own unacceptable feelings or impulses in other people instead of in him/herself.
Tends to be unconcerned with the consequences of his/her actions; appears to feel immune or invulnerable.
Tends to be energetic and outgoing.
Is inattentive or easily distracted; has trouble concentrating.
Not at all Slightly Partially Strongly Completely N/A
Is able to form close and lasting friendships.
Tends to break things or become physically assaultive when angry.
Tends to seek thrills, novelty, adventure, etc.
Easily jealous
Falls for new friends intensely, expects too much too quickly
Changes friends constantly, loves them one day and hates the next
Fears they will be rejected or abandoned
Feels others are out to get him/her
Acts overly seductive or sexy, flirts a lot
Attracted to unsuitable romantic partners
Not at all Slightly Partially Strongly Completely N/A
Emotions spiral out of control, has extremes of rage, despair, excitement
Cannot think when upset, becomes irrational
Unable to soothe or comfort self
Lacks stable image of self, changes goals/values
Expresses emotions in an exaggerated dramatic way
Irritable, touchy, or quick to “fly off the handle”
Angry and hostile
Engages in self-harm behavior