Emotional Needs Questionnaire

Copyright © 1986 by Willard F. Harley‚ Jr.

Name__________________________________ Date__________________________

This questionnaire is designed to help you determine your most important emotional needs and evaluate your spouse’s effectiveness in meeting those needs. Answer all the questions as candidly as possible. Do not try to minimize any needs that you feel have been unmet. If your answers require more space use and attach a separate sheet of paper.

Your spouse should complete a separate Emotional Needs Questionnaire so that you can discover his or her needs and evaluate your effectiveness in meeting those needs.

When you have completed this questionnaire‚ go through it a second time to be certain your answers accurately reflect your feelings. Do not erase your original answers‚ but cross them out lightly so that your spouse can see the corrections and discuss them with you.

The final page of this questionnaire asks you to identify and rank five of the ten needs in order of their importance to you. The most important emotional needs are those that give you the most pleasure when met and frustrate you when unmet. Resist the temptation to identify as most important only those needs that your spouse is not presently meeting. Include all your emotional needs in your consideration of those that are most important.

A. Need for affection: Indicate how much you need affection by circling the appropriate number:

How often would you like your spouse to be affectionate to you?

_______________   times each day/week/month (circle one).

If you are not shown affection by your spouse as often as you indicated above‚ how does it make you feel (circle the appropriate letter)?

B. Evaluation of spouse’s affection: Indicate your satisfaction with your spouse’s affection toward you by circling the appropriate number.

My spouse gives me (circle the appropriate letter)

Explain how your need for affection could be better satisfied in your marriage.

A. Need for sexual fulfillment: Indicate how much you need sexual fulfillment by circling the appropriate number.

How often would you like your spouse to engage in sexual relations with you?

____________   times each day/week/month (circle one)

If your spouse does not engage in sexual relations with you as often as you indicated above‚ how does it make you feel (circle the appropriate letter)?

B. Evaluation of sexual relations with your spouse: Indicate your satisfaction with your spouse’s sexual relations with you by circling the appropriate number.

My spouse gives me (circle the appropriate letter)

Explain how your need for sexual fulfillment could be better satisfied in your marriage.

A. Need for conversation: Indicate how much you need conversation by circling the

How often would you like your spouse to talk with you?

_______________ times each day/week/month (circle one).

If your spouse does not talk with you as often as you indicated above‚ how does it make you feel (circle the appropriate letter)?

B. Evaluation of conversation with your spouse: Indicate your satisfaction with your spouse’s conversation with you by circling the appropriate number.

My spouse gives me (circle the appropriate letter)

Explain how your need for conversation could be better satisfied in your marriage.

A. Need for recreational companionship: Indicate how much you need recreational

How often would you like your spouse join you in recreational activities?

_______________times each day/week/month (circle one).

If your spouse does not join you in recreational activities as often as you indicated above‚ how does it make you feel (circle the appropriate letter)?

B. Evaluation of recreational companionship with your spouse: Indicate your satisfaction with your spouse’s recreational companionship with you by circling the appropriate number.

My spouse gives me (circle the appropriate letter)

Explain how your need for recreational companionship could be better satisfied in your marriage.

A. Need for honesty and openness: Indicate how much you need honesty by circling the

Which of the following areas of honesty and openness would you like from your spouse (circle the letter(s) that apply to you)?

If your spouse fails to be open and honest in those areas that you indicated above‚ how does it make you feel (circle the appropriate letter)?

B. Evaluation of spouse’s honesty and openness: Indicate your satisfaction with your spouse’s honesty and openness with you by circling the appropriate number.

My spouse is (circle the appropriate letter)

Explain how your need for honesty & openness could be better satisfied in your marriage.

A. Need for an attractive spouse: Indicate how much you need an attractive spouse by circling the appropriate number:

Which of the following ch‎aracteristics of attractiveness mean the most to you (circle the letter(s) that apply to you)?

If your spouse does not have those ch‎aracteristics that you circled above‚ how does it make you feel (circle the appropriate letter)?

B. Evaluation of spouse’s attractiveness: Indicate your satisfaction with your spouse’s attractiveness by circling the appropriate number.

My spouse is (circle the appropriate letter)

Explain how your need for an attractive spouse could be better satisfied in your marriage.

A. Need for financial support: Indicate how much you need financial support by circling the appropriate number:

How much money would you like your spouse to earn to support you (and your children)? _______________

If your spouse does not earn the amount you indicated above‚ how does it make you feel (circle the appropriate letter)?

B. Evaluation of spouse’s financial support: Indicate your satisfaction with your spouse’s financial support of you by circling the appropriate number.

My spouse (circle the appropriate letter)

Explain how your need for financial support could be better satisfied in your marriage.

A. Need for domestic support: Indicate how much you need domestic support by circling the appropriate number:

How much time would you like your spouse to be engaged in domestic support?

_______________hours each day/week/month (circle one).

If your spouse does not spend as much time engaged in domestic support as you indicated above‚ how does it make you feel (circle the appropriate letter)?

B. Evaluation of spouse’s domestic support: Indicate your satisfaction with your spouse’s domestic support by circling the appropriate number.

My spouse gives me (circle the appropriate letter)

Explain how your need for domestic support could be better satisfied in your marriage.

A. Need for family commitment: Indicate how much you need family commitment by circling the appropriate number:

I have no need I have a moderate need I have a great need

How much time would you like your spouse to be engaged in family commitment?

_______________hours each day/week/month (circle one).

If your spouse does not spend as much time engaged in family commitment as you indicated above‚ how does it make you feel (circle the appropriate letter)?

B. Evaluation of spouse’s family commitment: Indicate your satisfaction with your spouse’s family commitment by circling the appropriate number.

My spouse (circle the appropriate letter)

Explain how your need for family commitment could be better satisfied in your marriage.

A. Need for admiration: Indicate how much you need admiration by circling the appropriate number:

How often would you like your spouse to admire you?

_______________times each day/week/month (circle one).

If your spouse does not admire you as often as you indicated above‚ how does it make you feel (circle the appropriate letter)?

B. Evaluation of spouse’s admiration: Indicate your satisfaction with your spouse’s admiration toward you by circling the appropriate number.

My spouse gives me (circle the appropriate letter)

Explain how your need for admiration could be better satisfied in your marriage.

Ranking of Your Emotional Needs

The ten basic emotional needs are listed below. There is also space for you to add other emotional needs that you feel are essential to your marital happiness‚ but are not included in the list.

In the space provided in front of each need‚ write a number from 1 to 5 that ranks the need’s most importance to your happiness. Write a “1” before the most important need‚ a “2” before the next most important‚ and so on until you have ranked all five.

To help you rank these needs‚ imagine that you will only have one need met in your arriage.

Which would make you the happiest‚ knowing that all the others would go unmet? That need should be “1.” If only two needs would be met‚ what would your second se‎lection be? Which five needs‚ when met‚ would make you the happiest.

____________________ Affection

____________________ Sexual Fulfillment

____________________ Conversation

____________________ Recreational Companionship

____________________ Honesty and Openness

____________________ An Attractive Spouse

____________________ Financial Support

____________________ Domestic Support

____________________ Family Commitment

Admiration____________________

________________________ ___________________

________________________ ___________________

________________________ ___________________

________________________ ___________________

Thoughts about My Parents

Please answer the following questions about your mother and your father. If you do not have any contact with one of your parents (for example‚ your father)‚ but there is another adult of the same gender living with your house (for example‚ a stepfather) then please answer the questions about that other adult.

If you have no contact with one of your parents‚ and there is not another adult of that same gender with whom

you live‚ then leave the questions about that parent blank.

Please use the following scale:

1. My mother seems to know how I feel about things.

2. My mother tries to tell me how to run my life.

3. My mother finds time to talk with me.

4. My mother accepts me and likes me as I am.

5. My mother‚ whenever possible‚ allows me to choose what to do.

6. My mother doesn't seem to think of me often.

7. My mother clearly conveys her love for me.

8. My mother listens to my opinion or perspective when I've got a problem.

9. My mother spends a lot of time with me.

10. My mother makes me feel very special.

11. My mother allows me to decide things for myself.

12. My mother often seems too busy to attend to me.

13. My mother is often disapproving and unaccepting of me.

14. My mother insists upon my doing things her way.

15. My mother is not very involved with my concerns.

16. My mother is typically happy to see me.

17. My mother is usually willing to consider things from my point of view.

18. My mother puts time and energy into helping me.

19. My mother helps me to choose my own direction.

20. My mother seems to be disappointed in me a lot.

21. My mother isn't very sensitive to many of my needs.

22. My father seems to know how I feel about things.

23. My father tries to tell me how to run my life.

24. My father finds time to talk with me.

25. My father accepts me and likes me as I am.

26. My father‚ whenever possible‚ allows me to choose what to do.

27. My father doesn't seem to think of me often.

28. My father clearly conveys his love for me.

29. My father listens to my opinion or perspective when I've got a problem.

30. My father spends a lot of time with me.

31. My father makes me feel very special.

32. My father allows me to decide things for myself.

33. My father often seems too busy to attend to me.

34. My father is often disapproving and unaccepting of me.

35. My father insists upon my doing things his way.

36. My father is not very involved with my concerns.

37. My father is typically happy to see me.

38. My father is usually willing to consider things from my point of view.

39. My father puts time and energy into helping me.

40. My father helps me to choose my own direction.

41. My father seems to be disappointed in me a lot.

42. My father isn't very sensitive to many of my needs.

Responses for each item take the form of 1=always false‚ 2=mostly false‚ 3=partly false and partly true‚ 4=mostly true‚ and 5= always true.

1. I like the way I look.

2. I have a happy family.

3. I don't sleep well.

4. It's hard for me to do what's right.

5. I know as much as the other children in my class.

6. I'm happy with who I am.

7. I don't feel well as I should.

8. It's hard for me to be around other people.

9. I don't do well in school‚ even I try.

10. I really care about my family.

11. I'm as nice as I should be .

12. I don't feel happy when I'm smart.

13. It's hard for someone to be my friend.

14. My family doesn't trust me.

15. My teacher thinks I am smart.

16. I get along well with other people.

17. I hate myself.

18. I'm not the person I would like to be.

19. H am an honest person.

20. I feel good most of time.

21. My body is healthy.

22. I am a decent sort of person.

23. I'm a cheerful person.

24. I'm not important at all.

25. My family will always help me.

26. I am a friend person.

27. Boys like me.

28. I don't always tell the truth.

29. I get angry sometimes.

30. I have lots of aches and paints.

31. I am a sick person.

32. Math is hard.

33. I have a lot of self-control.

34. I'm not a nice person.

35. I am not loved by my family.

36. Girls like me.

37. I'm mad at the whole world.

38. Once in a while I think of things too bad to talk about.

39. Sometimes when I am not feeling well‚ I get cranky.

40. I don't want to change the way I look.

41. I'd like to change some part of my body.

42. I think I do the right things most of the time.

43. I understand what I read.

44. I wish I could be more trustworthy.

45. I know my family as well as I should.

46. I'm as friendly as I want to be.

47. I do not like everyone I know.

48. Sometimes I laugh at a dirty joke.

49. I shouldn't tell so many lies.

50. I'm as smart as I want to be.

51. I should love my family more.

52. I'm not as smart as the other children in my class.

53. It's easy for me to do a good job on my homework.

54. I am a bad person.

55. I should get along better with other people.

56. Sometimes h feel like swearing.

57. I take good care of my body.

58. I often clumsy.

59. I some times do very bad things.

60. I do things without thinking about them first.

61. I try to be fair with my friends and family.

62. I do what my parents want me to do‚ even when I don't agree with them.

63. I don't forgive other people easily.

64. I'm not good at sports and games.

65. I sometimes cheat.

66. I solve my problems very easily.

67. I fight with my family.

68. I don't act the way my family think I shoud.

69. Most people are good.

70. I find it hard to talk with people I don't know.

71. Sometimes I put off until tomorrow what I ought to do to day.

72. I know the answers to questions the teacher asks.

73. I do what's right most of times.

74. I'm happy with the way I treat other people.

75. I'll never be as smart as other people.

76. I like to do math.

W.H.Fitts‚ ph.D. and W.L.warren‚ ph.D.

Kramschuster. Jenny. Lynn :  A Research Paper‚ Submitted in Partial Fulfillment of the Requirements for the ma‎ster of Science Degree With a Major in Guidance and Counseling The Graduate College . University of Wisconsin-Stout. August‚ 2001

Difficulties in Emotion Regulation Scale (DERS)

Serenity Programme™ - www.serene.me.uk

Difficulties in Emotion Regulation Scale (DERS)

Date Identifier

Please indicate how often the following 36 statements apply to you by writing the appropriate number from the scale above (1 – 5) in the box alongside each item.

Gratz‚ K.L. & Roemer‚ E. Multidimensional Assessment of Emotion Regulation and Dysregulation: Development‚ Factor Structure‚ and Initial Validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment‚ 26: 1‚ pp. 41-54

by Allan Fenigstein‚

Michael Scheier‚ and Arnold Buss

http://www.psychbytes.com/Quizzes/Self%20Consciousness%20-%20Multiple%20Scores/Self%20Consciousness%20Scale.htm

Ralf Schwarzer‚ Manfred Diehl‚ & Gerdamarie S. Schmitz‚ 1999

This scale refers to post-intentional self-regulation when individuals are in the phase of goal-pursuit and face difficulties in maintaining their action.  In such a maintenance situation it is required to focus attention on the task at hand and to keep a favorable emotional balance.  Thus‚ attention-regulation and emotion-regulation are reflected in these scale items.

In a sample of N = 442 persons the scale has obtained an internal consistency of Cronbach's alpha = .76.  In a sample of N = 239 persons the scale yielded a retest stability of .62 after six weeks.

There were associations found with general self-efficacy beliefs (r = .57)‚ and with proactive coping (r = .55).

Note: (–) indicates the item has to be reversed.
Response format:
(1) not at all true‚ (2) barely true‚ (3) moderately true‚ (4) exactly true

34. Beginning -‎- You hear a friend talking about a new job opening at the local book store. You love books and want a job. You decide you would like to work at the bookstore.

35. Beginning -‎- Your friends are acting like they are mad at you. You are upset about this.

36. Beginning -‎- You go to your English class one morning and discover your English book is not in your backpack. You are upset because you need that book to do your homework.

37. Beginning -‎- You are in a club at school. The club advisor announces that the club members will need to elect new officers at the next meeting. You want to be the president of the club.

Ending -‎- The story ends with you being elected as the club president.

38. Beginning -‎- You are at a new school and you don't know anyone. You want to have friends.

Where do you want to live when you graduate?

Where do you want to work after you graduate?

What type of transportation do you plan to use after graduation?

42. I usually do what my friends want.

I tell my friends if they are doing something I don't want to do.

43. I tell others when I have new or different ideas or opinions.

44. I usually agree with people when they tell me I can't do something.

I tell people when I think I can do something that they tell me I can't.

45. I tell people when they have hurt my feelings.

I am afraid to tell people when they have hurt my feelings.

46. I can make my own decisions.

Other people make decisions for me.

47. Trying hard at school doesn't do me much good.

Trying hard at school will help me get a good job.

48. I can get what I want by working hard.

I need good luck to get what I want.

49. It is no use to keep trying because that won't change things.

I keep trying even after I get something wrong.

50. I have the ability to do the job I want.

51. I don't know how to make friends.

I know how to make friends.

52. I am able to work with others.

I cannot work well with others.

53. I do not make good choices.

I can make good choices.

54. If I have the ability‚ I will be able to get the job I want.

I probably will not get the job I want even if I have the ability.

55. I will have a hard time making new friends.

I will be able to make friends in new situations.

56. I will be able to work with others if I need to.

I will not be able to work with others if I need to.

57. My choices will not be honored.

I will be able to make choices that are important to me.

© 1995‚ The Arc of the United States and Michael Wehmeyer (nonexclusive rights). All rights reserved. No part of this book may be reproduced by any means without prior written permission from the publisher.

The Motives for Physical Activity Measure - Revised (MPAM-R) is a questionnaire intended to assess the strength of five motives for participating in physical activities such as weight lifting‚ aerobics‚ or various team sports. The five motives are: (1) Fitness‚ which refers to being physically active out of the desire to be physically healthy and to be strong and energetic; (2) Appearance‚ which refers to being physically active in order to become more physically attractive‚ to have defined muscles‚ to look better‚ and to achieve or maintain a desired weight; (3) Competence/Challenge‚ which refers to being physically active because of the desire just to improve at an activity‚ to meet a challenge‚ and to acquire new skills; (4) Social‚ which refers to being physically active in order to be with friends and meet new people; and (5) Enjoyment‚ which refers to being physically active just because it is fun‚ makes you happy‚ and is interesting‚ stimulating‚ and enjoyable. The scale has been used to predict various behavioral outcomes‚ such as attendance‚ persistence‚ or maintained participation in some sport or exercise activity‚ or to predict mental health and well-being. The different motives have been found to be associated with different outcomes.

The scale is a revision of an earlier measure by the same name‚ which was shorter and included only three motives (Frederick & Ryan‚ 1993). The longer version was introduced and validated by Ryan‚ Frederick‚ Lepes‚ Rubio‚ and Sheldon (1997).

Frederick‚ C. M.‚ & Ryan‚ R. M. (1993). Differences in motivation for sport and exercise and their relationships with participation and mental health. Journal of Sport Behavior‚ 16‚ 125-145.

Ryan‚ R. M.‚ Frederick‚ C. M.‚ Lepes‚ D.‚ Rubio‚ N.‚ & Sheldon‚ K. M. (1997). Intrinsic motivation and exercise adherence. International Journal of Sport Psychology‚ 28‚ 335-354.

Motives for Physical Activities Measure – Revised (MPAM-R)

The following is a list of reasons why people engage in physical activities‚ sports and exercise. Keeping in mind your primary physical activity/sport‚ respond to each question (using the scale given)‚ on the basis of how true that response is for you.

___ 1. Because I want to be physically fit.

___ 2. Because it’s fun.

___ 3. Because I like engaging in activities which physically challenge me.

___ 4. Because I want to obtain new skills.

___ 5. Because I want to look or maintain weight so I look better.

___ 6. Because I want to be with my friends.

___ 7. Because I like to do this activity.

___ 8. Because I want to improve existing skills.

___ 9. Because I like the challenge.

___ 10. Because I want to define my muscles so I look better.

___ 11. Because it makes me happy.

___ 12. Because I want to keep up my current skill level.

___ 13. Because I want to have more energy

___ 14. Because I like activities which are physically challenging.

___ 15. Because I like to be with others who are interested in this activity.

___ 16. Because I want to improve my cardiovascular fitness.

___ 17. Because I want to improve my appearance.

___ 18. Because I think it’s interesting.

___ 19. Because I want to maintain my physical strength to live a healthy life.

___ 20. Because I want to be attractive to others.

___ 21. Because I want to meet new people.

___ 22. Because I enjoy this activity.

___ 23. Because I want to maintain my physical health and well-being.

___ 24. Because I want to improve my body shape.

___ 25. Because I want to get better at my activity.

___ 26. Because I find this activity stimulating.

___ 27. Because I will feel physically unattractive if I don’t.

___ 28. Because my friends want me to.

___ 29. Because I like the excitement of participation.

___ 30. Because I enjoy spending time with others doing this activity.