If you’ve found yourself here you’re obviously facing a [personal, relationSHIP, parenting or family] challenge & exploring healing options...

Life’s challenges are tough … and also opportunities for personal growth & deeper connection.

With this in mind, you’re invited to create some uninterrupted space to complete the questionnaire below.

… There’s a fair chance that by taking the time to complete the questionnaire you’ll gain deeper insight into your current issue … and beyond that I will personally respond to you with suggested next steps on your healing journey.

I’m here for you! You’ve got this!

Much Love,

Emma

EARLY ATTACHMENT HISTORY QUESTIONNAIRE …

Name

First Name

Last Name

Phone

(###)

###

####

Briefly describe your current personal/ relationship/ parenting/ family issue requiring support:

EARLY ATTACHMENT HISTORY QUESTIONNAIRE

You are invited to create some uninterrupted, quiet time to complete this questionnaire. Please watch your inbox for my personal reply & recommendations. * Please answer each question as honestly as possible. * You can skip any questions that you don't feel comfortable asking. * Your responses will be kept confidential & used for the purpose of better understanding your attachment history.

Age

Gender

Current family structure

Section 1. Primary caregivers.

Who were your primary caregivers during your early childhood (Eg. parents, grandparents, foster parents etc.)

2. How would you describe your relationship with your primary caregiver(s) during your early years.

Eg. very close, close, neutral, distant, very distant. Add any insights.

3. Did you feel safe & secure with your primary care giver(s)?

Eg. Always, often, sometimes, rarely, never. Add any insights.

Section 2. Emotional support.

4. How often did your primary caregiver(s) respond to your emotional needs? Eg. Always, often, sometimes, rarely, never. Add any insights.

5. How did your primary caregiver(s) typically express affection?

e.g. hugs, praise, gifts etc. Add any insights.

6. Where there any significant events in your early childhood that affected your relationship with your caregiver(s)?

Section 3. Experiences of separation & loss.

7. Did you experience any separations from your primary caregiver(s) during your early years? If yes please describe.

8. How did you cope with those separations?

9. Did you experience any significant losses in early childhood?

e.g. death of a loved one, divorce etc.

Section 4. Social relationships.

10. How would you describe your friendships during early childhood? e.g. very positive, positive, neutral, negative, very negative. Add any insights.

11. Did you find it easy or difficult to make friends as a child?

e.g. very easy, easy, neutral, difficult, very difficult. Add any insights.

12. How did your relationship with peers influence your emotional development?

Section 5. Reflection & Impact.

13. How do you believe your early attachment experiences have influenced your relationships in adulthood?

14. What patterns do you notice in your current relationships that may stem from your early attachment experiences?

15. Is there anything else you would like to share about your early attachment history?