PERSONAL LIFE ASSESSMENT QUESTIONNAIRE: This is an initial questionnaire intended only for those who seek online or offline psychotherapy/counseling. You'll receive a FREE personal feedback and results after you've completed the form and other pertinent details. To assure that you'll receive the results of your questionnaire, feedback, and other resources, simply complete your details below (double check the accuracy of your email address). Cheers!

* Your Full Name

* Country of Origin:

* Your Email Address

* Mobile Phone Number

Questionnaire Instruction: Indicate how you're doing in each of the following key areas of your life by selecting a number from 1 through 5 below each statement.

1 = Ashamed to Say
2 = Need Major Tuneup
3 = Need Modest Change
4 = Need Fine Tuning
5 = Doing Great

* 1. Is your weight about right?

* 2. Are you eating a healthy, balanced diet?

* 3. Do you limit your use of drugs?

* 4. Are you exercising vigorously 3 to 4 times a week?

* 5. Are you keeping your body toned by stretching daily?

* 6. Are you getting enough rest and sleep?

* 7. Do you express love and caring easily and frequently?

* 8. Are you finding time to maintain your friendships?

* 9. Are dealing honestly with conflicts as they arise?

* 10. Do you have a satisfying sex life with your wife/husband?

* 11. Do you have at least one relationship where you feel totally accepted?

* 12. Do you feel sustained by your relationships?

* 13. Are you reading enough good books?

* 14. Are you informed about and involved in larger social and world issues?

* 15. Are you exposing yourself to stimulating, new ideas?

* 16. Does your lifestyle reflect your basic values?

* 17. Do you take time periodically to reflect on the purpose of your life?

* 18. Are you finding meaning in your life as a whole?

* 19. Are you engaged in satisfying work?

* 20. Are you pleased with the activities that capture most of your time?

* 21. Are you making the kind of contribution to others you want to?

* 22. Are you making good use of your talents?

* 23. Are you having fun and enjoying your fair share of belly laughs?

* 24. Are you content with what you've achieved thus far?

* 25. Are you starting most days with energy and confidence?

* 26. Do you feel good about your options and prospects?

* 27. Do you have a support system that assists you in achieving your goals?

* 28. Are you living mostly in the present as opposed to the past and future?

* 29. Are you in control of your use of time?

* 30. Are you coping well with the inevitable losses that come to all of us?

* Personal Comments and Suggestions:

* Indicates Response Required