Quiz1 - Rebuilders International, LLC

Divorce Adjustment Self-Assessment

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I like being the person I am

Almost Always Usually Sometimes Seldom Almost Never

I can communicate with my ex or Soon-to-be-ex in a calm and rational manner

Almost Always Usually Sometimes Seldom Almost Never

There are many things about my personality I would like to change

Almost Always Usually Sometimes Seldom Almost Never

I feel like I am an attractive person

Almost Always Usually Sometimes Seldom Almost Never

There are many things about my body I would like to change

Almost Always Usually Sometimes Seldom Almost Never

I am relating and interacting in many new ways with people since my separation

Almost Always Usually Sometimes Seldom Almost Never

Joining a singles group would make me feel I was a loser like them

Almost Always Usually Sometimes Seldom Almost Never

I feel like unloading my feelings of anger and hurt upon my former love partner

Almost Always Usually Sometimes Seldom Almost Never

I hope my former love partner is feeling as much or more emotional pain than I am

Almost Always Usually Sometimes Seldom Almost Never

10.

I am unable to control my emotions

Almost Always Usually Sometimes Seldom Almost Never

11.

I am afraid to trust people who might become love partners

Almost Always Usually Sometimes Seldom Almost Never

12.

I either have no appetite or eat continuously which is unusual for me

Almost Always Usually Sometimes Seldom Almost Never

13.

I have given up on my former love partner and getting back together

Almost Always Usually Sometimes Seldom Almost Never

14.

I feel very frightened inside

Almost Always Usually Sometimes Seldom Almost Never

15.

It is important that my family, friends, and associates be on my side rather than on my former love partner's side

Almost Always Usually Sometimes Seldom Almost Never

16.

I feel uncomfortable even thinking about dating

Almost Always Usually Sometimes Seldom Almost Never

17.

I have noticed my body weight is changing a great deal

Almost Always Usually Sometimes Seldom Almost Never

18.

I avoid people even though I want and need friends

Almost Always Usually Sometimes Seldom Almost Never

19.

I sigh a lot

Almost Always Usually Sometimes Seldom Almost Never

20.

I believe it is best for all concerned to have our love relationship end

Almost Always Usually Sometimes Seldom Almost Never

21.

I feel adequate as a fe/male love partner

Almost Always Usually Sometimes Seldom Almost Never

22.

Life is somehow passing me by

Almost Always Usually Sometimes Seldom Almost Never

23.

I am afraid of becoming emotionally close to another love partner

Almost Always Usually Sometimes Seldom Almost Never

24.

Even on the days when I am feeling good, I may suddenly become sad and start crying

Almost Always Usually Sometimes Seldom Almost Never

25.

I can't believe our love relationship is ending

Almost Always Usually Sometimes Seldom Almost Never

26.

I become upset when I think about my love partner dating someone

Almost Always Usually Sometimes Seldom Almost Never

27.

People want to have a love relationship with me because I feel like a lovable person

Almost Always Usually Sometimes Seldom Almost Never

28.

I feel comfortable going to social events even though I am single

Almost Always Usually Sometimes Seldom Almost Never

29.

I understand the reasons why our love relationship did not work out

Almost Always Usually Sometimes Seldom Almost Never

30.

I need to improve my feelings of self-worth about being a wo/man

Almost Always Usually Sometimes Seldom Almost Never

31.

What is your gender?

Female

Male

Prefer not to say

32.

>What do you do during normal work hours?

Stay at home parent

Physical/Active type of job

Managerial job

Desk Job

Not currently working/Other

33.

> Where are you in the divorce process?

34.

How do you feel about your income versus expenses?

There are a lot of different types of income and a lot of expenses. When you look at your bank account, in general, is there more money in it each month or less? Your answer to this will help us best help you address one of the most critical impacts of divorce.

My income is significantly greater than my expenses

My income is somewhat greater than my expenses

My income is about the same as my expenses

My income is somewhat less than my expenses

My income is significantly less than my expenses

35.

What do you think about YOUR debt?

Two people might have the same amount of debt but perceive it very differently. What is your perception of your debt situation?

I'm very worried about my debt

I'm a little worried about my debts

I think my debt is manageable

I'm totally covered. I feel good about the debt that I have, if any.

36.

Do you have money that is working for YOU?

401ks, investing in stocks, investing in a house, and so many other things help your money work for you so that you don't have to. In divorce, this may be something you lose or gets reduced significantly.

Yes, I've invested well and I have multiple ways that my money is increasing

Yes, I have one thing that is working for me.

No, but I plan to start soon

No, and I have no idea where to even begin.

37.

Do you have a financial safety net?

Life happens, and then a surprise bill hits. Can you absorb it?

Yes, if a major expense hit I could probably cover it.

I have a little bit of a cushion against expenses

I would be in trouble if an unexpected expense was needed

No, anything would be difficult for me

38.

>Do you have kids?

None

0-5 years old

6-12 years old

13-18 years old

19 or older

39.

What level of conflict is/was there in the divorce?

As the conflict in a divorce rises it has a higher impact on children.

It is/was a very amicable separation/divorce

There is/was some conflict but not much

There is/was a fair amount of conflict in the separation/divorce

It is/was a very high-conflict separation/divorce

40.

How concerned are you about the effect of your divorce on your children?

Skip this question if you don't have children

Very concerned

Somewhat concerned

Not sure

Not too concerned

Not at all concerned

41.

How would you describe your parenting situation with your ex?

Select "Not Applicable" if you don't have children.
Independent parenting is typically in high-conflict divorces in which the way in which children are raised is very different. Each parent makes their own choices, rules, routines, etc.
Parallel parenting means that each parent has differences in choices, rules, and routines but they are similar and each parent is aware of the situation at the other parents house.
Collaborative parenting means that the parenting is identical and both parents work hard to be consistent and cooperative with each other.

Independent

Parallel

Collaborative

Not Applicable

42.

How well are you sleeping these days?

Most nights are poor sleep

Some nights are poor sleep

Most nights I get decent sleep

I always sleep well

43.

How do you feel about what you are eating these days?

I always eat healthy food

I eat healthy food most of the time

I eat unhealthy food less often than healthy food

I rarely eat healthy food

44.

How do you feel about how you are taking care of your body?

It might be exercise, relaxation, etc. Whatever works for you

I am doing something for my body most days of the week

I am doing something for my body a few days of the week

I do something for my body occasionally

I rarely do something for my body

45.

Do you have a daily routine that you follow?

I get up at the same time most days

I go to sleep at the same time most days

I keep busy most days

I eat regularly throughout the day

46.

Do you have friends or family in your life that you can talk to about your divorce?

Yes, I have a number of people that I can talk to

Yes, I have one person that I can talk to

No, I don't have anyone that I feel comfortable talking to about my divorce

No, but I don't think I need to

47.

Are you talking to a professional counselor/therapist/coach?

Yes

No, and I don't plan to

No, but I would like to find someone that I feel comfortable with

48.

How would you rate the communication between you and your ex or soon to be ex?

Terrible

It's not good

It's okay

Excellent

49.

Do you know other people that have gone through divorce that you can talk to about yours?

Yes, I know at least a few

Yes, I know one

No, and I don't want to

No, but I want to

50.

How optimistic are you for your future?

I'm struggling to enjoy today, let alone the future

I think I will be okay some day

Each day is getting better

I'm looking forward to starting a new chapter

51.

How difficult has your divorce been for you?

Very difficult

Hard

Some days good, some days bad

Pretty easy

Very easy

52.

Do you know what you want to do with the rest of your life ?

No idea, I haven't even thought about it

I have some dreams that I am considering

I have some things that I am starting

I have started Rebuilding my future

Every day I am actively creating my new future

53.

Do you believe you will love someone again?

No, I have no interest in being in a loving relationship ever again

Not right now but maybe sometime in the future

Maybe.

Yes but it will take the right person

Absolutely! I know there is someone great out there for me.

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