Break Through to Love Assessment Logo - Large (Swirl Design)
 Catching Kismet Break Through to Forever Love Assessment v2.0 (Backup - 06-26-17)

First Name:
Last Name:
Email:
Phone Number:
Relationship Status:
Section 1. Please answer the following questions about your experience of dating. If you are not currently dating, please answer the questions based upon your attitudes towards dating when you last dated.
Section 1. Please answer the following questions about your experience of dating. If you are not currently dating, please answer the questions based upon your attitudes towards dating when you last dated.
I have had a hard time finding someone who is the total package, and there is no way I would settle for anything less.
True
False
I am hung up on a guy that I would love to date, but he either doesn’t know how I feel or doesn't feel the same way.
True
False
I oftentimes find it hard to get out of the friend zone with men.
True
False
I don't seem to be able to get past the first or second date with guys.
True
False
I tend to attract:
A lot of men.
Enough men.
Few men.
Where are all the men?
I am good at flirting and know how to signal a man that I am interested.
True
False
It is common for men to get the wrong idea and think that I'm interested even when I'm not.
True
False
When searching for the right guy, I tend to date:
One man at a time. Even at the beginning of a relationship, I don't consider dating anyone else.
Multiple men casually until I decide to get serious with one of them.
I have taken enough time to heal my heart from my last relationship.
True
False
I would love to be in a successful romantic relationship right now.
True
False
Having a successful romantic relationship is an important part of having a full life.
True
False
The way I feel about getting out there and dating is:
I feel OK about it. I am actively dating right now.
I am so busy, I don't see where I would find the time to date.
Dating is hard so I distract myself with other things.
I could make time for dating, but I am not ready to get back out there yet.
I could make time for dating, but I'm not interested.
Dating is full of more disappointment than enjoyment.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I can find something positive in just about every first date I have.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
I embrace dating as an opportunity to meet new people, and make new friends.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
I feel crushed when a guy doesn’t contact me again after a first date I thought went well.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
I feel very anxious about the process of meeting new men to date.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
I feel very anxious even when I am in a committed relationship with a guy.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
I feel very anxious when I am dating someone before we are in a committed relationship.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
I feel very anxious when waiting for a guy I’m interested in to call or text me.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
I feel very awkward on a first date.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
I feel very depressed that I only seem to attract men who are not right for me.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
I feel very disappointed after a first date with a guy who is not someone I could see myself actually dating.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
I feel very disappointed when a man whose profile I really like does not write back to me online.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
I feel very disappointed when not enough men contact me online.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
I feel very frustrated that few men that I meet or go on first dates with are men I could ever see myself dating long-term.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
Sometimes dating sucks so much that I stop dating for awhile.
Strongly Disagree
Somewhat Disagree
Neither Agree nor Disagree
Somewhat Agree
Strongly Agree
Section 2. Through the following questions, we are analyzing patterns in your most significant relationships. Please answer the questions in the affirmative if you have noticed the following feelings, attitudes, and experiences in your most significant relationships. If multiple answers are true, pick the answer you feel is most common or most significant for you. In situations where one answer may have been true in the past, while another is true of your more recent relationships, answer according to what is true for you now.
Section 2. Through the following questions, we are analyzing patterns in your most significant relationships. Please answer the questions in the affirmative if you have noticed the following feelings, attitudes, and experiences in your most significant relationships. If multiple answers are true, pick the answer you feel is most common or most significant for you. In situations where one answer may have been true in the past, while another is true of your more recent relationships, answer according to what is true for you now.
It is common for me to feel jealous or fearful that my guy might be interested in another woman.
True
False
All men struggle with being faithful, but the good ones will overcome it.
True
False
I don't want to fully commit because I believe someone better might come along and I will be stuck.
True
False
If you could have only one of the following three qualities in a partner, which would you choose?
An intense soulmate connection.
A good, kind person.
Someone who will always be there to take care of me.
I tend to lose my own identity and/or spend a lot less time with friends when I am in a relationship.
True
False
I tend to give more than I receive.
True
False
I thrive on being needed by my guy. I have a strong desire to take care of my man.
True
False
It is important to me that I show my guy no one will ever love him like I can.
True
False
In the beginning of my relationships, I usually feel:
An almost instantaneous magnetic attraction. It would be hard to resist our connection.
Drawn to the person, but I don't let myself fall too fast.
Not totally into it, but I typically give a guy a chance anyway.
I typically feel comfortable having sex in a new relationship:
Right away. If we are both feeling it, why wait?
I don't have a specific time table. It just happens when I feel comfortable.
It takes awhile. I want to make sure that I really get to know the person first.
I like to wait until I am in a committed relationship first.
Only after we are married.
When I find someone I like, I typically:
Take my time and really get to know the other person before getting into a relationship.
Jump into a relationship very quickly.
I can't help it - the type of men I typically attract are: (Please select all that apply.)
Commitment-phobes.
Clingy, needy or sensitive.
Cheaters.
Emotionally and/or physically unavailable.
Angry, controlling, and/or abusive.
Immature.
Bitter about their past.
Good guys.
Players.
Bad boys.
My feelings towards a guy can run hot and cold, but once they turn cold that's usually the end of the relationship.
True
False
How much time do you typically spend with your romantic partner?
I never get to spend enough time with my guy.
An adequate amount - we are both happy with the amount of time we spend together.
He wants to spend more time than I have available.
When you spend time together, your guy usually finds a time that works for:
His schedule, without regard for yours.
Your schedule. He is very accommodating.
Both of your schedules.
I am not my guy's top priority. He has other people or situations in his life that he prioritizes over our relationship.
True
False
Who typically ends your relationships?
I do.
My romantic partner does.
Section 3. In the following questions, we are examining some of your core beliefs about relationships. Some responses will resonate with you more than others. For each question, please select all responses that you feel strongly represent an attitude that you have. If you are having difficulty choosing, try to discern which ones "feel" like a match.
Section 3. In the following questions, we are examining some of your core beliefs about relationships. Some responses will resonate with you more than others. For each question, please select all responses that you feel strongly represent an attitude that you have. If you are having difficulty choosing, try to discern which ones "feel" like a match.
Please take your time to select all of the following relationship beliefs that reflect attitudes that you hold about relationships. (Please select at least 1.)
I will be hurt if I initiate contact with you.
I am safe if I hold on to you.
I will be absorbed if I get close.
If I act independent, you will abandon me.
I'll be safe if I stay in control.
I'll be loved if I go along and please others.
I'll be loved if I am the best.
I'll be loved if I am good and cooperative.
I'll be hurt if I try to be close.
I'll be loved if I meet your needs.
I'll be controlled if I give up dissent.
I have to hold things together.
Please take your time to select all of the following core beliefs that reflect attitudes that you hold. (Please select at least 1.)
I have no right to exist.
I can't get my needs met.
I can't say no and be loved.
I can't count on anyone.
I can't be me and be accepted and loved.
I'll never be seen, valued, and accepted.
I have to be perfect.
I don't know what to do; I can't be aggressive or express anger.
I am not lovable.
Others need me.
I am not trusted.
I have to be good.
Please take your time to select all of the following that reflect common negative ways that you view your romantic partners. (Please select at least 1.)
Demanding, all consuming.
Unavailable, has no feelings, a rock wall
Insecure, too dependent; needy
Distant, has no needs.
Unorganized, scatterbrained, over-emotional
Insensitive, controlling.
Manipulative, incompetent
Never satisfied; has to win.
Gregarious and intrusive
Unappreciative
Too nice, counter-controlling, guilting, parental
Rebellious child.
Please take your time to select all of the following common frustrations that you have when you are in a relationship. (Please select at least 1.)
You hate me, you feel too much.
You are never there.
You need too much.
You are never there when I need you.
You want me to be somebody else; you don't know what you want.
You never see me; you want everything your way.
You are never satisfied.
You always have to win.
You don't like me; you won't leave me alone.
You don't appreciate me or my efforts.
You are never on my side
You won't grow up; you always want to be different.
Section 4. Please answer the following questions:
Section 4. Please answer the following questions:
As I look back, I find that I typically ignore my friends’ advice about the men that I date, and go with my feelings instead.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I desire total emotional closeness with my romantic partners.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Each day I devote time to fulfilling my life’s purpose.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Every week, I engage in activities that bring me joy and make me feel alive.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
My romantic partners typically don't desire as much emotional closeness I do.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I am able to say “no” to people without guilt, even those with whom I am close.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
There have been times that my romantic partners have been scared away by the level of emotional closeness I desire.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I am compassionate towards myself.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I am still crazy about my ex, and it keeps me from moving forward with other relationships.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I am concerned about being as good as other people, and there are times I don't think I am.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I believe that I have limiting beliefs about love, dating, relationships, or myself that are keeping me from attracting my soulmate.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I can quickly name 5 activities that bring me joy and make me feel energized and happy to be alive.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I am typically worried that my romantic partners don't care about me as much as I care about them.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I can recognize red flags.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I feel comfortable ending a relationship if I see red flags.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I worry that my romantic partners don't really love me.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I feel completely lovable just as I am.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I have 4 or more dates a month.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I worry that my romantic partners will stop loving me.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
I have a strong network of close friends who love and support me unconditionally.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I have close friends who tell me the truth instead of just telling me what I want to hear.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I worry that my romantic partners will leave me.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I have good examples of people close to me who are in successful, happy marriages.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I have taken time to define the qualities I am looking for in a mate.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I worry that my romantic partners will find someone else.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I have trouble being my authentic self with men.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I know how to balance my drive for career success at work with femininity when I am with my man.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I am very independent and self-sufficient, even in a romantic relationship.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
I know the characteristics of my perfect guy, and I won’t settle for anything less.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I know what my life’s purpose is.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
It is not necessary for me to be in a close, committed relationship.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I listen to what a man says, but I only make decisions based upon what he does.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I love myself.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I prefer not to depend upon my romantic partners.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I prioritize my own needs.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I prioritize my own self-care.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I feel uncomfortable sharing deeply personal thoughts and feelings even with my romantic partners.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I recognize when I am not being treated with dignity and respect.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
The number one need a man wants fulfilled in a relationship is:
Love
Respect
Faithfulness
Friendship
I feel uncomfortable when my romantic partner depends upon me too much.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I turn to family and/or friends during challenging times in my life.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I use my thoughts and feelings to attract my life partner.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I feel uncomfortable when my romantic partners talk about their thoughts and feelings.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
If someone does not treat me with dignity and respect, I have no problem communicating how I feel to that person or ending a relationship, if necessary.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
It has been at least 6 months since I went out on a date.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I tend to keep my problems to myself and figure them out alone.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
My friends give me advice about the men that I date.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
My parents are happily married.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I want a romantic partner who knows how to figure out their own problems themselves.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
On dates, I often find myself thinking about what is happening instead of being fully present with my date.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
There are painful events from my past that I haven’t completely let go of.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
When I am having a difficult time, I have people I can turn to.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Section 5. The questions below will provide an important dimension to your assessment results, so please try to answer them as candidly as possible.
Section 5. The questions below will provide an important dimension to your assessment results, so please try to answer them as candidly as possible.
Did a household member go to prison?
Yes
No
Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
Yes
No
Did a parent or other adult in the household often or very 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?
Yes
No
Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
Yes
No
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
Yes
No
Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
Yes
No
Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Yes
No
Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Yes
No
Was a household member depressed or mentally ill, or did a household member attempt suicide?
Yes
No
Were your parents ever separated or divorced?
Yes
No
Section 6. Please answer the following questions:
Section 6. Please answer the following questions:
As a youth, people noticed that I was capable and could get things done.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
When I was young, I was independent and a go-getter.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
When I was young, I believed that life is what you make it.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
I believe that my father loved me when I was little.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
I believe that my mother loved me when I was little.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
I’ve heard that when I was an infant someone in my family enjoyed playing with me, and I enjoyed it, too.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
My family, neighbors and friends talked often about making our lives better.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
Someone in my family cared about how I was doing in school.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
We had rules in our house and were expected to keep them.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
When I felt really bad, I could almost always find someone I trusted to talk to.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
When I was a child, neighbors or my friends’ parents seemed to like me.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
When I was a child, teachers, coaches, youth leaders or ministers were there to help me.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
When I was a child, there were relatives in my family who made me feel better if I was sad or worried.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
When I was little, other people helped my mother and father take care of me and they seemed to love me.
Definitely true
Probably true
Not sure
Probably not true
Definitely not true
Section 7. Please answer the following questions with a rating between 0 and 10.
Section 7. Please answer the following questions with a rating between 0 and 10.
How in touch with your authentic painful emotions are you when you experience a challenging or difficult time in your life? 0 - Not in touch at all 10 - Totally in touch
How dedicated have you been over the course of your life to activities that will help you to understand yourself better and heal. (e.g. psychotherapy, hypnosis, EFT, etc.) 0 - Not dedicated, 10 - devote time each day.
How much of a connection have you been able to see between events that happened in your childhood, and events that happened/happen in your life as an adult? 0 - See no connections, 10 - Frequenly see connections.
How much do you believe that you are still impacted in your life today by the events that occurred in your childhood? 0 - Not impacted, 10 - Very impacted.
How much have you completely forgiven everyone who has hurt you in any way in your life? 0-Forgiven no one 10-Forgiven everyone
We typically have painful repeating patterns of events or situations that commonly occur in our lives - to what degree have you learned the lessons from those patterns and eliminated them from your life. 0-Eliminated NO Painful patterns 10-Eliminated ALL painful patterns
How painful are the patterns you experience in your life? 0-Not painful at all 10-Extremely painful
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