AAI forms | Dr. Kim Wyatt-Brooks

Adult Attachment Interview

Questionnaire 1 of 2

Demographic Information

Adult Attachment Interview

Questionnaire 2 of 2

Your Initials

1. Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you? OR act in a way that made you afraid that you might be physically hurt?

2. Did a parent or other adult in the household often push, grab, slap, or throw something at you? OR ever hit you so hard that you had marks or were injured?

3. Did an adult or person at least 5 years older than you ever touch you or fondle you or have you touch their body in a sexual way? OR try to or actually have oral, anal, or vaginal sex with you?

4. Did you often feel that no one in your family loved you or thought you were important/special? OR that your family didn’t look out for or support each other?

5. Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? OR that your parents were too drunk or high to take care of you or take you to the doctor?

6. Were your parents ever separated or divorced?

7. Was a parent/carer often pushed, grabbed, slapped, or had something thrown at them? OR sometimes/often kicked, bitten, hit with a fist, or hit with a something hard? OR ever repeatedly hit for a few minutes or threatened with a gun/knife?

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

9. Was a household member depressed or mentally ill? OR did a household member attempt suicide? OR did a household member commit suicide?

Adverse Childhood Experiences (ACEs) Questionnaire

Adult Attachment Interview

Adult Attachment Interview

Thank you!

Optional : pick your own pseudonym...