Object Relations Assessment Survey
Please complete this survey to help us understand your perceptions and experiences in relationships.
Full Name
*
First Name
Last Name
Age
*
Which type of relationship are you primarily reflecting on in this survey?
*
Family
Friendship
Romantic
Professional/Work
Other
How would you describe your feelings and thoughts about yourself in this relationship?
*
How would you describe your feelings and thoughts about the other person in this relationship?
*
Which of the following emotions do you most frequently experience in this relationship? (Select all that apply)
Trust
Closeness
Anxiety
Distance
Ambivalence
Other
Do you feel that experiences from past relationships influence your current relationships?
Yes
No
Not Sure
Please share any additional comments or insights about your relationships that you believe are important for this assessment.
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