Full Name
Email
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Phone
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1. I feel I need to cover up for irresponsible people in my life because I don’t want them to suffer.
Yes
No
2. I feel it’s my job to fix, manage and hold my family / relationship together.
Yes
No
3. When I get in close relationships, I change to please that person.
Yes
No
Maybe
4. Other people’s needs come before mine, even if I have urgent needs and they don’t.
Yes
No
5. I cover up my feelings with drug, alcohol use, sex, gambling, food or other things outside of myself.
Yes
No
6. I find it difficult to speak what I truly feel or ask for what I need.
Yes
No