Name
*
First Name
Last Name (optional)
Email
*
example@example.com
1. I often wonder if I left that toxic relationship too soon, or if I didn't do enough to save it.
*
Often
Occasionally
Sometimes
Rarely
2. It’s hard to talk about what happened to my friends and family because I'm not sure how much to say.
*
Often
Occasionally
Sometimes
Rarely
3. I feel stuck.
*
Often
Occasionally
Sometimes
Rarely
4. I’ve lost friendships and other social connections since that relationship.
*
Yes
No
5. I feel guilty about what happened in that relationship even though I did everything possible to save it.
*
Often
Occasionally
Sometimes
Rarely
6. I can’t believe I let this person into my life.
*
Often
Occasionally
Sometimes
Rarely
7. I catch myself sharing too many details about what happened.
*
Often
Occasionally
Sometimes
Rarely
8. I’m struggling to go no contact with this person.
*
Yes
No
9. Sometimes I revisit old letters, emails, photos, and text messages looking for answers or to feel close to that person.
*
Often
Occasionally
Sometimes
Rarely
10. Flashbacks of good or bad memories catch me off guard.
*
Often
Occasionally
Sometimes
Rarely
11. I’m easily startled or jumpy.
*
Often
Occasionally
Sometimes
Rarely
12. I have a lot of stuffed rage over what happened?
*
Often
Occasionally
Sometimes
Rarely
13. Bouts of unexpected sadness or feeling blue come over me.
*
Often
Occasionally
Sometimes
Rarely
14. I don’t know if I’ll ever date again, or if I’ll fully trust another person again.
*
Often
Occasionally
Sometimes
Rarely
15. I find it challenging to meet people, try new things, or visit old favorite places.
*
Often
Occasionally
Sometimes
Rarely
16. Since that relationship, I’ve been more guarded.
*
Often
Occasionally
Sometimes
Rarely
17. The thought of making new friends or having a romantic interest makes me nervous.
*
Often
Occasionally
Sometimes
Rarely
18. I sometimes wonder if I was the problem in that relationship.
*
Often
Occasionally
Sometimes
Rarely
19. Since meeting that toxic person, my world feels smaller.
*
Yes
No
20. I’m not sure the next right step to advance my healing from that toxic relationship?
*
Definitely
At times
Not sure
No, I need help
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