Professional Documents
Culture Documents
Name:
Address:
Date: Date of Birth:
5. What adults, other than your mother and father, had a decisive influence on your life
when you were young (identify and describe):
8. What did she say when she was upset or felt bad:
11. Did that agree with what you wanted? If yes, have you got it? If no, how did you
resolve the difference:
16. Did that agree with what you wanted? If yes, have you got it? If no, how did you
resolve the difference:
17. What other names have you been known by and/or called yourself? What special
meaning did/do these have for you? For others (identify):
19. Does this equate to what the world wants you do be:
20. Briefly describe how grown-ups talked to you as a child:
21. When you were punished, what was mild and what was severe:
23. What thoughts, feelings, or attitudes were you not to reveal in your childhood:
24. What do you like most about yourself? What would you like others to most like in
you:
26. What did you say and believe about life as a teenager:
27. What did you say and believe about life when in grade school:
29. What is there about yourself you are most eager to change:
30. How do you handle disagreement:
31. What are your requirements for a person to be your friend? Are these your
requirements or what you were told to expect:
34. In childhood, what special, unusual, and/or foreign words were taught to you to
substitute for the name of body functions, parts of the body, and/or sex:
35. Which of these have you passed along, or do you still use:
41. Describe the bad feeling you have most often experienced:
44. What person in the story did you like best, and what did you like about the person:
45. Suppose your present troubles continue, what will you be doing five years from now:
46. If you change in the ways you desire, what will you be doing five years from now:
48. At what age have you thought you would die and how would death occur:
49. If you were to die today, what would you write on your tombstone? What is the final
word on the epitaph which you didn’t have room for:
55. How does your practice add to, subtract from, or confuse your present lifestyle:
56. Is this the same religion you were taught to practice as a child:
58. Suppose magical changes were possible, what or how would you change:
59. What do you want most out of life:
60. What were you denied as a child which you are presently denying yourself:
61. Who or what is your biggest obstacle in your life right now:
62. What do you expect will be done in the process of the change you now seek:
63. List the ways you might sabotage those changes you seek: