| 1. What is the age of your daughter? |
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| 2. What kinds of activities do you participate in with your daughter? |
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| 3. What is your greatest joy in being a mother? |
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| 4. What one area of your relationship would you most like to improve? |
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| 5. Both of us would say that our relationship is excellent. |
Less True - 1 2 3 4 5 - More True
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| 6. Both of us would say that we spend enough time interacting with each other on a daily basis. |
Less True - 1 2 3 4 5 - More True
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| 7. When we talk with each other, we both listen deeply and respect each others differences. |
Less True - 1 2 3 4 5 - More True
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| 8. What are your greatest concerns for your daughter? |
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| 9. Based on your present mother and daughter relationship, what can you see it looking like five years from now? |
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| 10. I would spend time and money for an overnight retreat with my daughter. |
| Less True - 1 2 3 4 5 - More True |
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