Name: Email: Phone: What issue do you want insight into? How have you felt over the last two weeks? Please click on your answer to each question below: Section I 1. Do you frequently ask yourself what your “purpose” is? 0-never 1- rarely 2-occasionally 3-often 4-many 2. “If I only had the time or money I would be able to….”? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Do you find yourself feeling lost? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Do you find yourself seeking direction from others? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section II 1. Do you feel overloaded? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Do you feel overwhelmed with too many options? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Do you feel as if you can’t see the forest for the trees? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Do you feel numb? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section III 1. Do you feel unprepared? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Do you have a lot of unfinished projects? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Are you faced with many ideas not coming to fruition? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Do you get caught off guard often? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section IV 1. Do you have anxiety? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Are you uneasy facing the unknown? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Do you feel more comfortable being in control? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Do you give up easily? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section V 1. Are you angry? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Do you have a hard time being direct? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Do you have to be right? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Are you opinionated? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section VI 1. Do you feel unsafe? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Do you feel guarded? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Are you aggressive? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Are you afraid of appearing vulnerable? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section VII 1. Are you exhausted? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Does it take a lot of courage to do your daily tasks? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Are you ready to run? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Does life seem unfair? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section VIII 1. Are you spacey? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Do you feel ungrounded? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Are you off center with yourself? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Is the sweetness of life gone? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section IX 1. Are you experiencing loss over and over again? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Do you feel oppressed? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Is your creativity blocked? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Are you under a lot of pressure? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section X 1. Are you experiencing a lost love? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Has the joy gone from your life? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Do you have a hard time sharing your feelings? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Do you act cheerful in spite of how you feel? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section XI 1. Do you have trust issues? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Do you feel unsupported? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Are you grieving a loss or misunderstanding? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Do you have anguish? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section XII 1. Does life feel complicated? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Are you having a hard time digesting a situation? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Are your relationships unfulfilling? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Do you feel “I can’t stomach this”? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section XIII 1. Are you explosive? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Are your dreams continually thwarted? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Are you sad? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Are you depressed? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section XIV 1. Have your judgments been off? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Are you bitter about your life or a situation? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Do you feel stuck? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Are you resentful? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section XV 1. Are you unnourished by the way you live your life? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Are you starved for love or happiness? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Do you have a hard time receiving? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Do you have cravings? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section XVI 1. Are you emotionally or physically constipated? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Do you feel stuck in a situation or relationship? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Is your relationship toxic? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Do you sell out to keep love? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section XVII 1. Do you worry a lot? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Do you feel uncertain? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Do you get lost in your concerns? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Are you confused about what action to take? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section XVIII 1. Are you afraid? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Is a relationship poisoned? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Do you have a hard time discerning what is good for you? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Do you have a hard time going with the flow? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section XIX 1. Are you “pissed”? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Do you suppress how you really feel? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Do you disconnect when you are faced with feeling your anger? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Do you hold on to old hurts? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section XX 1. Do you have a hard time letting go of the past? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Do you tend to have relationships that are “one way”? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Have you not learned the lessons from the past? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Do you feel unclear about how to move forward? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section XXI 1. Do you feel unstable? 0-never 1- rarely 2-occasionally 3-often 4-many 2. When faced with unexpected, are you rigid in your response? 0-never 1- rarely 2-occasionally 3-often 4-many 3. Do you have a hard time being flexible? 0-never 1- rarely 2-occasionally 3-often 4-many 4. Is your life structured? 0-never 1- rarely 2-occasionally 3-often 4-many Next Section XXII 1. Do you have a hard time defining your boundaries? 0-never 1- rarely 2-occasionally 3-often 4-many 2. Do you have a hard time asking for what you need? 0-never 1- rarely