The 6 Selves Model of Self-Inquiry Assessment
Please complete this form as honestly as possible. The more information I have the more accurately I can direct, guide and support you. All information is kept strictly confidential. If you find any question to be too private or personal you can choose to simply write NA. 
Sign in to Google to save your progress. Learn more
Email *
Untitled Title
First Name *
Last Name: *
How would you prefer us to contact you about the results?
Clear selection
Mobile/ Cell (so we can contact you faster than email. Please include area code):
Gender: *
DOB: *
MM
/
DD
/
YYYY
Country and City you live in: *
Occupation: *
Who referred you to me? *
PERSONAL HISTORY 
The more detail and accuracy that I have the better I can assist. Some of the following questions and sections will apply more to you than others. Do your best to answer all questions.  I understand that these questions are private and personal in nature and may trigger an emotional response. If you need to discuss anything urgently or feel you are in a crises situation, please contact the following counselling services:

Lifeline Australia - 13 11 14 
1800RESPECT (Domestic or sexual violence) 
Beyond Blue 1300 224 636
 

Personal History comprises of the following sections representing key life areas and is based on my coaching model of emotional self-inquiry, The 6 SELVES. 

1. The Spiritual Self (connection to life)
2. The Emotional (responding rather than reacting)
3. The Legacy Self (connection to your purpose personally and professionally)
4. The Valued Self (valuing yourself personally and professionally)
5. The Ecological Self (surrounding yourself with those who lift yet challenge you)
6. The Sexual Self (connecting to your sensuality and creative expression)
THE SPIRITUAL SELF
I believe that a solid spiritual life is the foundation to a joyful life. This may encompass religious beliefs and rituals or it may be a gratitude practice, mindfulness techniques or breath work. Being aware of this aspect of self allows for greater success in all areas of life and contributes to a life that is meaningful, purposeful and connected. Connection to this aspect of self also contributes to a clear mind, a loving and kind heart, a body that feels strong and resilient as well as a spirt or soul that is open to the experience of being human. All of which contribute to a more fulfilling personal and professional life. 
What does a 'spiritual life' mean to you? *
How often do you meditate? (include how many years, times per week/ what technique and why that technique?) *
Do you identify with any particular religion? If so which one? *
What term resonates the most with you? *
Do you believe in past lives? (If yes please share some experiences including what technique etc.) *
Do you currently work with a healer or any other spiritual teacher? If yes, what are you working on and why? *
Anything else about your spiritual life that you want to share?
THE EMOTIONAL SELF
A solid emotional life is a key component to a peaceful life. When our emotions or our energy (chi/ shakti) are out of alignment, we can experience many highs and lows that often become traumatic or dramatic in nature. When we are able to master our emotions life flows with ease and effortlessness. Opportunities find us and our relationships tend to be smooth and loving.  This aspect of self also contributes to our decision making abilities and allows us to respond rather than react. As a result, we utilise our logical and reasonable mind as well as our heart and emotions to make decisions that impact us positively in the short and long term.  Connection to this aspect also offers us the ability to overcome obstacles and challenges that arise throughout our lifetime. This section will help me to identify any current gaps in your regime. 
Have you in the past or are you currently seeing any of the following therapists? *
If you answered 'yes' to the above, please tell me in more detail: How often you see or saw them? What particular life area did you focus on? Did or does the therapy work why or why not? *
If you had access to the best therapists, mentors or coaches in the world, what life area would you want to focus on? (money/ business / romance/ sex/ relationships / spirituality etc.) What do you believe would happen to your overall life if this area was finally 'sorted out'? *
Have you ever done any energetic or emotional work on your family lineage or inner child? If 'yes' did you benefit from the experience why or why not? *
Anything else about your emotional life that you want to share?
THE LEGACY SELF 

Every human holds within their DNA a blueprint that provides purpose and meaning to both their personal and professional lives. This aspect of self, shifts and changes depending on what chapter of life you find yourself in. Perhaps you find yourself raising a family, caring for ageing parents, starting, growing or exiting a business or changing directions in your career. Connecting more deeply with your legacy self will open new doorways of possibility and add a dimension of depth to your experience of life. 

What industry are you in? (How long for? Have you worked in other industries if so which ones?) *
What category best describes you? *
Tell me a bit more about who you work for or what your business does? *
How long have you been in this role? (what were you doing just prior?  *
In this current role(s) what are you enjoying the most?
In this current role(s) what are you least enjoying?
If you have a website what is it?
What area of your personal life is working really well and what area do you believe requires more attention? *
If you could 'wave a magic wand' regarding your legacy self, what would you create?
Who inspires you or who do you aspire to be like and why? (this might be a celebrity or a person close to you)
Have you ever published a book? If yes please let me know more about it such as where it is available. *
If you were to overhear a conversation between two trusted family members or friends describing how you had touched their lives, what would they say? *
If you could pick the values that best described your current version of self. What would you choose?  (This may take some time but is well worth the effort) 

1. Select each value you would identify as congruent with and relevant to you both personally and professionally 

2. Refine that initial list to a top ten.

3. Further refine this top ten list down to a top five list of your key values. You may choose to have a seperate list for your personal and professional life. 

Please note: You may highlight your top list or type them out below.

Accountability  Achievement  Adaptability  Adventure Ambition  Aesthetics  Authenticity  Balance  Beauty Boldness  Bravery  Candid  Caring  Change  Clarity Collaboration Communication Community Competitive Connection Conversations Conviction Cooperation Courage Courtesy Creativity Curiosity  Daring Dedication  Depth  Development  Dignity  Discretion Diversity  Drive  Duty  Empathy  Energy Entrepreneurship Environment  Equality  Ethics  Excellence  Expertise Faith  Family  Flexibility  Freedom  Fresh  Friendship Fulfilment  Fun  Generosity  Greatness  Growth Happiness  Harmony  Hard work  Healing   Helpful Independence  Individuality  Innovation  Insight Intelligent  Introspection  Integrity  Involvement  Joy  Justice   Kindness  Knowledge  Leadership Learning  Legacy  Loyalty  Love  Mastery  Money  Nature Objective  Openness  Order  Partnership  Passion  Patience  Peace  Perceptive  Perfection  Perseverance  Personal growth   Personal development Professionalism  Quality  Relationships   Respect Responsibility   Responsiveness   Risk taking   Safety Sanctuary   Security   Self-worth   Service  Sharing Simplicity  Stability  Strength  Success  Tastemaker Teamwork  Tough  Tradition  Trust  Truth  Understanding Unique  Variety  Virtue  Wisdom Youthful 




 *
THE VALUED SELF 
Your time, energy, money and wisdom are valuable assets. When you are honouring these aspects within yourself as well as within others, life flows and brings with it joyful and meaningful experiences. A healthy version of this self will allow you to set and express healthy boundaries in your interpersonal relationships. It will also offer you insight into any gaps within your communication that may be blocking you from asking for a raise, speaking your truth, charging more or investigating multiple income streams that align with you. 
How would you describe your relationship with time over the past few months?  Some examples may be 'I feel I never have enough' or 'I often feel like I take on too much'  *
How would you describe your relationship with energy over the past few months?  Some examples may be 'I feel exhausted or over burdened' or 'I feel high on life'  *
How would you describe your relationship with money over the past few months?  Some examples may be 'I feel I often have enough' or 'I feel lacking and fearful'  *
How would you describe your relationship with wisdom over the past few months?  Some examples may be 'I feel quite philosophical about life' or 'I feel life is hard or overwhelming'   *
How much do you earn on average per year? (before tax. This includes jobs, businesses, investments, inheritance and support from a spouse)   *
How much money would you be willing to invest in yourself (per year) if you knew that your life would benefit in every way? *
How many hours per week (on average) would you be willing to invest in yourself if you knew that your life would benefit in every way? *
THE ECOLOGICAL SELF 
When we are spending time, energy and money on and with people who value our truest self, we feel a sense of belonging.  We also feel a sense of being challenged in positive ways to reach more evolved and fulfilling versions of ourselves. This 'tribe' mentality offers us the perfect balance of freedom and security.  However, what happens when we feel we have out grown or evolved to the point where parts of our lives feel inauthentic? It may be time to review and gain clarity on where and with whom to spend your precious resources.  This clarity and connection also offers you the ability to positively impact your life and the lives of those you love and care for at work and at home.
How confident do you feel on average when you walk into a room of beautiful and successful people? *
Regarding the above question, can you elaborate why this is so? *
How much impact do you believe you have (on average) within your family: *
How much impact do you believe you have (on average) within your business / workplace: *
How much impact do you believe you have (on average) within the world at large: *
Now that you have answered the above, what would you like the above answers to be regarding family/ work / the world? *
What do you believe stops you the most from achieving those results? *
What statement best describes you? *
Please share a bit more about your answer above: *
Do you have any members of your family that really trigger you? Please share why exactly. *
Do you have a particular old friend or old flame that really (even years later) causes you emotional pain? Please share why exactly. *
THE SEXUAL (CREATIVE) SELF
Congratulations you are almost done! 

I have witnessed that a level of comfort about this topic pays for itself in every other life area. Research suggests that connection to our sexuality and our sensuality not only benefits our physical well-being, it also improves our mental and cognitive functioning.  When we have accessed our sexual vibrancy our confidence increases and our ability to communicate more effectively strengthens.  Lastly, we heighten our creative expression through writing, speaking, painting, drawing or any other means when this 'self' is activated.
What statement best describes you: (regardless of your current relationship status) *
Over the past few weeks have you felt you have lost your 'mojo'? *
Are you feeling passionate, invigorated and alive both at home and at work? Why/ why not? *
If you could feel more confident sexually would you be open to discussing this topic? (why / why not?) *
Anything else about your sexual life that you want to share? *
THE END
Thank you for your honesty and time. I will analyse the results and contact you via your preferred method or discuss the findings at your discovery session.  If you have any questions please email debbie@debbiezita.com or visit www.debbiezita.com.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Debbie Zita. Report Abuse
Google Forms