Name *

First Name

Last Name

Question 1 *

Does the way you feel about yourself on a day to day basis depend on things outside of your control? e.g. Things other people say or do.

Yes

No

Question 2 *

Do you associate your self worth with the things you have accomplished and/or the services you provide to others?

Yes

No

Question 3 *

Quickly, mentally list 5 things that you love about yourself. Was this a tricky exercise?

Yes

No

Question 4 *

Have there been times in your life that you have questioned who you really are, your identity and what you stand for?

Yes

No

Question 5 *

If you hear about other things that people have accomplished, do you start wondering whether you have the skills to accomplish the same?

Yes

No

Question 6 *

Think about when you were a child. Were you told that the world was a scary place and that it's very dangerous to take risks?

Yes

No

Question 7 *

Think about when you were a child. Was there a significant adult present within your childhood that seemed anxious or nervous about particular things such as work, home, image, family image, money etc.

Yes

No

Question 8 *

Think about when you were a child. Was there a significant adult present within your childhood who struggled to meet their own goals because of their own lack of progress?

Yes

No

Question 9 *

Think about when you were a child. Was there a significant adult present within your childhood who seemed overly critical of you or held you to a really high standard?

Yes

No

Question 10 *

Reflect back on your life and whether you had at least one role model for the major accomplishments of your life, or whether you had to find your own way?

Yes, I had to find my own way

No, I had at least one

Question 11 *

Do you prefer routine and familiarity and tend to get frustrated at things or people that tend to throw you off your routine?

Yes

No

Question 12 *

Reflecting back on the parts of your life that involved significant change (e.g. moving house, job etc) do you remember more of the nervousness rather than the excitement of the change?

Yes

No

Question 13 *

Do you feel rather nervous and worried when you don't know what to expect in a particular situation?

Yes

No

Question 14 *

When you decide to start pursuing an important goal for yourself, is one of your main concerns, what if I fail?

Yes

No

Question 15 *

Have you experienced at least once in your life a time that you decided to take a chance on something new that failed miserably and now has led you to be more apprehensive with your life choices?

Yes

No

Question 16 *

Has someone called you a 'control freak' at least once in your life?

Yes

No

Question 17 *

Do you have a tendency to at least try and have the last word in an argument?

Yes

No

Question 18 *

Do you often find yourself being a harsh critic of yourself, but maybe of others too?

Yes

No

Question 19 *

Do you have a tendency to correct other people on things even if that thing is something insignificant?

Yes

No

Question 20 *

I hope you have been really open and trust that all of this is both private and confidential, but also powerful fuel for insight and growth. Please give me a very honest answer here for this last one. Do you struggle to admit when you are wrong?

Yes

No

Thoughts about this exercise *

This process was a challenge for me because I wrangled with my truth.

Pick the closest matching option

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Feelings about the exercise *

I feel like I wanted to have different answers for some of the questions.

Rate your answer to this statement

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree