Directions: Answer the following and discuss before watching TV, using
the telephone, or other activity.

     1.     When I said: " . . . . . . . " I was (mark all that apply):
    
             Blaming
             Criticizing
             Threatening
             Accusing
             Generalizing                        
             Giving an order or command
             Showing little concern of other’s needs
             Showing unwillingness to compromise or find solutions
             Insulting, name calling, mocking, being sarcastic
             Other:

     2.     When I said the above comment, I was probably feeling:

             Tired
             Rushed
             Impatient                        
             Annoyed
             Other

     3.     When I said the above comment, others probably felt:

             Angry
             Hurt
             Sad
             Rejected                        
             Scared
             Frustrated
             Shocked
             Other:

        . . . and they are not likely to want to (check all that apply):
                     
             Do the following for me _________________________________
                     
             Help me: ____________________________________________

             Other:

     4.     Instead of making the above comment, I could have said:

     5.     I would have been less likely to make the above comment if
             others had approached me by saying:

     6.     If others say I made the above comment and I deny it, the
             following are possible:

             Being corrected makes me feel bad.

              I have an evil twin.
              I am not aware of my words and behavior.
              Others are hallucinating.
              I am trying to avoid dealing with it.

     7.      When I don’t admit mistakes I make, others feel:

                     Frustrated
                     Angry
                     Confused
                     Distrustful
                     Other:

     8.      When I admit mistakes, others feel:

                     Relieved
                     Trustful
                     Proud of me
                     Other: