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Origins & Influences Questionnaire

Understanding What May Have Shaped My Behaviour

This questionnaire is designed to help identify experiences, patterns and influences that may have contributed to a behaviour becoming important in your life. It is not a diagnostic tool. There are no right or wrong answers. Please answer broadly rather than specifically.

Scoring: 0 = Not at all  |  1 = A little  |  2 = Sometimes  |  3 = Often  |  4 = Very much
0 of 20 answered0%

Relationships & Connection

1. Growing up, I often felt unsupported, misunderstood or emotionally alone.
Question 1
2. I often felt different from other people.
Question 2
3. I often felt lonely, isolated or disconnected from others.
Question 3
4. I learned that it was safer or easier to deal with problems on my own.
Question 4

Feelings & Coping

5. Growing up, I learned healthy ways of dealing with difficult feelings.
Question 5
6. I find some feelings difficult to sit with for long.
Question 6
7. I often look for something to help me escape, switch off or feel better.
Question 7
8. When life becomes difficult, I am not always sure how to cope in healthy ways.
Question 8

Difficult Experiences

9. There were experiences growing up that felt frightening, overwhelming or unsafe.
Question 9
10. I experienced criticism, bullying, humiliation or rejection that affected me deeply.
Question 10
11. I experienced significant losses, separations or disruptions that had a lasting impact.
Question 11
12. There are experiences from my past that still affect me today.
Question 12

Shame, Secrets & Self-Worth

13. There were things in my family, relationships or life that were difficult to talk about openly.
Question 13
14. I have often felt not good enough.
Question 14
15. I have spent time hiding parts of myself from other people.
Question 15

The Behaviour

16. The behaviour was easy to access when I first discovered it.
Question 16
17. The behaviour quickly became a reliable way of feeling better, escaping or coping.
Question 17
18. At the time, I did not have many other ways of meeting the same need.
Question 18

Looking At Things Today

19. Although the behaviour creates problems, part of me still relies on it.
Question 19
20. I am not always sure what need the behaviour is trying to meet.
Question 20

Looking Back

If this was trying to help you in some way, what do you think it was helping you with?

Reflection

Complete the 20 scored questions above, then press this button to create the score card below.

Therapist Summary

Domain totals update automatically from the questionnaire responses.

Domain
Questions
Total
Relationships & Connection
1–4
0 /16
Feelings & Coping
5–8
0 /16
Difficult Experiences
9–12
0 /16
Shame & Self-Worth
13–15
0 /12
Behaviour Development
16–18
0 /12
Current Relationship With Behaviour
19–20
0 /8

Therapist Notes

Areas that seem most relevant:

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