Assessment / Questionnaire
Answer each question on a scale of 1 to 5 = where #1 is NOT like you and #5 is very MUCH like you.
(each number represents a 20% range as indicated below)

#1 = is from 0% to 20%  = very seldom / rare / unlikely / not like me (includes 'never' and 'hardly ever')
#2 = is from 21% to 40% = occasionally
#3 = is from 41% to 60% = middle / not strongly associated either way... (try not to use this rating if possible - choose one side or the other)
#4 = is from 61% to 80% = somewhat like me / often
#5 = is from 81% - 100% = very much like me / almost always / always

Be as honest as possible.  Answer the questions quickly.  
Do not think about your answers or second guess them.  
Answer them based on how you are feeling / behaving lately.

There are no right or wrong answers.  Where you are is where you are and that's perfectly alright!  
Awareness is the first and most important key to knowing where you are, and moving towards your desired transformation.  
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Your Name:
Date:
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1. I am generally unsure of myself in new social situations (where I don't know anyone, or where I know only a few people):  (1 = not like you to 5 = very much like you)
Clear selection
2. When someone criticizes me, I replay this over and over in my head for days.
Clear selection
3. I easily get embarrassed.
Clear selection
4. I usually minimize my accomplishments and magnify my mistakes.
Clear selection
5. I am a "People Pleaser".
Clear selection
6. When someone mistreats me, I analyze the situation to try to determine what I must have done to cause it.
Clear selection
7. I worry a lot.
Clear selection
8. I have been hurt many times, and have trouble trusting other people.
Clear selection
9. I have difficulty accepting compliments.
Clear selection
10. Other people tend to be very critical of my actions and what I say.
Clear selection
11. I am a "Perfectionist" and would rather spend a lot of time trying to get something done RIGHT, rather than make and mistake and regret it.
Clear selection
12. I procrastinate a lot.
Clear selection
13. I feel better whenever I've discussed my problems with someone else.
Clear selection
14. I do everything possible to AVOID confrontations and disagreements.
Clear selection
15. Some people say I'm negative and pessimistic.
Clear selection
16. I often compare myself to others (and notice that they are better looking, smarter, or more capable than I am)
Clear selection
17. People tell me that I'm too sensitive, or that I take things too seriously / personally.
Clear selection
18. People take advantage of me.
Clear selection
19. I'm comfortable speaking up or sharing my opinions in a group.
Clear selection
20. I set clear goals for my future.
Clear selection
21. I am often very busy and overwhelmed.  There is SO much that I want to get done each day and never seem to have the time!
Clear selection
22. I worry about being criticized or rejected by others.
Clear selection
23. I'm very conscientious about my appearance (what I wear and how I look).  I never leave the house without looking my best.
Clear selection
24. I grew up in a very dysfunctional home.
Clear selection
25. I can't seem to do anything right or well.
Clear selection
26. I love trying new things that are OUTSIDE my Comfort Zone!
Clear selection
27. "Rude people" annoy me and get on my nerves!  (for example: bad drivers, insensitive co-workers or store clerks)
Clear selection
28. My body shows physical signs of my Anxiety: (ANY of the following: heart racing, insomnia, nausea, eating disorder, emotional instability, shallow breathing, brain fog, poor decision making abilities)
Clear selection
29. I have negative thoughts rattling around in my head (about myself, others, and/or my life)
Clear selection
30. My life is "tougher" than most other people's lives.
Clear selection
31. I feel very limited in my ability to succeed. (I just don't have enough money / education/ opportunities / skills / or luck)
Clear selection
32. Many of my family members and/or friends are more successful than I am.
Clear selection
33. In my sexual relationships, I rarely focus on my OWN satisfaction.
Clear selection
34. Talking about money makes me very uncomfortable.
Clear selection
35. I have faith in my own abilities.
Clear selection
36. I have a lot to be grateful for, and can list off endless blessings at ANY time!
Clear selection
37.  I need to keep busy (getting things DONE) or else I feel like I'm being "lazy".
Clear selection
38.  I have a lot of energy and it lasts throughout the entire day!
Clear selection
39.  My mind is as sharp (or sharper) than it has ever been.
Clear selection
40. I have a hard time talking about my accomplishments, achievements, and positive qualities with others.
Clear selection
41. Taking great care of myself is one of my TOP priorities (self-care, special treats like massages, getting enough sleep, eating healthy, hobbies, relaxing, rejuvenating)
Clear selection
42. There are a lot of things about my body that I do NOT like.
Clear selection
43. I don't like to ask for help.
Clear selection
44. I love working together with others in groups.
Clear selection
45. I have a hard time making eye contact with others (especially strangers).
Clear selection
46. I often initiate conversations with strangers (in the grocery store, on an elevator, etc.)
Clear selection
47. I feel very intimidated and uncomfortable around confident, successful people.  (It's almost as if their success makes me feel even more inadequate.)
Clear selection
48. If my order is not correct in a restaurant, I just accept it (rather than making a scene and letting the server know or getting it corrected).
Clear selection
49. I feel dissatisfied with one or more important areas of my life.
Clear selection
50. I have an overall feeling of being "in control" of my life!
Clear selection
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