Name ___________________________ Date
_______________ No. ____________
What kind of person are you now? Described yourself briefly.
Personal worth. How do you see yourself right now? Now become a child again in memory,
under the age of seven :
What kind of person was your mother? Describe your mother
briefly.
What kind of person was your father? Describe your father
briefly.
Did any other adults live in your home before you were 10
years old ? (If yes, briefly describe each of them.)
What was your mother's favourite saying about life?
How did your mother praise you - what did she say or do?
How did your mother criticise you - what did she say or do?
When mother was upset how did she show it ?
What did you do to help when mother was upset ?
What was her advice to you as a child ?
What was your mother's attitude towards money, religion,
sex, and education? What messages did she give you about this?
What was your father's favourite saying about life?
How did your father praise you - what did he say or do?
How did your father criticise you - what did he say or do?
When father was upset how did he show it ?
What did you do to help when father was upset ?
What was his advice to you as a child ?
What was your father's attitude towards money, religion,
sex, and education? What messages did he give you about this?
When you were punished what was mild and what was severe?
Which punishment was most common ?
What were you told about your birth?
What nicknames have you had ? What did they mean?
Briefly describe how grown-ups talked to you as a child.
What did your mother hope you would be ?
What did your father hope you would be ?
Are you closer to what mother wanted or what father wanted?
When did you decide on your profession or vocation in life and why ?
What do you remember about starting to school? When you were
seven how old were your old were your parents, brothers and sisters? List them by age and
name.
What feelings, thoughts or attitudes were you not to reveal
in your childhood ?
What did you say believe about life before you started
school?
What did say and believe about life when in primary school?
What did you say and believe about life as a teen-anger? How
was life for you in your teens?
What do you now say and believe about life?
What do you like most about yourself?
What do you dislike about yourself?
What childhood stores did you like best? If you can't think
of a story, who was your hero? Or a significant person in your childhood?
What childhood stores did you like best and what did you
like about the person? What was your favourite part of the story?
What dreams do you often have?
Have you ever thought that you had lost your mind, or that
such a thing might happen?
Do you ever feel that something might be wrong with you? (If
yes, ask what?)
If someone disagrees with you, do you generally argue or
give in ?
Do you believe you are getting nowhere or that life has no
purpose?
How do you picture yourself now - at what felt age - as a
child, a teenager, or adult?
Have you ever contemplated about suicide?
When did you last wish someone else would die?
Suppose you present troubles continue, what will you be in
another five years?
At what age have you thought you would die and how would
death occur?
What would you have written on your tombstone? What do you
want people to remember you for?
What might others have written on your tombstone? For what
are you known?
What physical symptoms do you frequently have?
When you feel upset or uncomfortable, describe the bad
feeling you most often have in your life.
How early in your life do you remember such feelings?
Describe the circumstances most often related to those
feelings.
How do you wish your mother might have been different?
How do you wish your father might have been different?
If you were given wishes, what or how would you change?
What do you most want in life?
What do you expect from me (the therapist, partner,
co-counsellor)?
Have you had treatment or counseling before - if yes,
explain.
How did you benefit?
How were you dissatisfied?
What do you hope will be done in the process of the change
you now seek?
How will you and I know that you have gotten what you came
for?
When you change in the way you want, what other troubles do
you believe you might have?
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