Adult Attachment Disorder Screening Questionnaire Form
Please answer the following questions to help screen for patterns related to adult attachment. Your responses are confidential and will be used to assess general attachment tendencies.
Full Name
*
First Name
Last Name
Age
*
How comfortable are you with depending on others for support?
*
Not at all comfortable
1
2
3
4
Very comfortable
5
1 is Not at all comfortable, 5 is Very comfortable
How often do you worry about being abandoned by people close to you?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
I find it difficult to trust others completely.
*
Strongly disagree
1
2
3
4
Strongly agree
5
1 is Strongly disagree, 5 is Strongly agree
I feel anxious when I am not in close contact with people I care about.
*
Strongly disagree
1
2
3
4
Strongly agree
5
1 is Strongly disagree, 5 is Strongly agree
When someone gets too close to me, I tend to withdraw.
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Which statement best describes your approach to close relationships?
*
I am comfortable with intimacy and independence.
I crave closeness but worry about rejection.
I prefer to keep some distance from others.
Other
Have you previously participated in therapy or counseling for relationship or attachment concerns?
Yes
No
Prefer not to say
Is there anything else you would like to share about your attachment or relationship experiences?
Submit Screening
Should be Empty: