P MYA WORKER NAME OR INITIALS AND DOB DATE

1. My mother seldom says nice things about me.

2. I am an important person in my mother’s eyes.

3. My mother often acts as if she doesn’t care about me.

4. My mother enjoys spending time with me.

5. My mother expresses her warmth and affection for me.

6. My mother is easy for me to talk to.

7. I am tense and uneasy when my mother and I are together.

8. I feel that my mother finds fault with me more than I deserve.

9. My mother takes an active interest in my affairs.

10. I feel very close to my mother.

11. My mother does not understand me.

12. My mother believes in me.

13. I don’t feel that my mother enjoys being with me

14. My mother doesn’t really know what kind of person I am.

15. My mother is a warm and caring individual.

16. My mother does not feel that I am interesting and important.

17. My mother is very interested in those things that concern me.

18. My mother is often critical of me and nothing I do seems to please her.

19. My mother seldom shows me any affection.

20. My mother consoles me and helps me when I am unhappy or in trouble.

21. My mother is generally cold and removed when I am with her.

22. I receive a lot of affirmation from my mother.

23. My mother is very understanding and sympathetic.

24. My mother does not really care about what happens to me.