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1. Hello Valued Life Insights' Client:
ACCEPTANCE OF THE FOLLOWING STATEMENTS REPRESENT A LEGAL COMMITMENT BY YOU SO PLEASE READ THE FOLLOWING VERY CAREFULLY!
Welcome to the Life Insights Adult Self Evaluation Questionnaire that is designed for adults 21 and older. The purpose of this questionnaire is to create a baseline of your self perceptions as a basis for identifying self-imposed limitations and opportunities for optimizing your future. A Life Insights mentor will review your data and schedule a time to discuss the results with you to clarify a mutual understanding and chart a path forward.
This data will be a reference point in Phase 3 of the Life Insights process where you will review the Life Insights summary of axioms and insights. Phase 3 is designed to introduce you to a higher awareness that will hopefully advance your life progression to achieve your goals and ambitions by providing you with a competitive advantage versus your peers.
The survey is somewhat lengthy in an an effort to create a comprehensive evaluation, but please take your time and carefully consider the answers to each question before answering. The end results of the Life Insights process are directly correlated to the accuracy and complete candor of your responses to this questionnaire. The answers are completely confidential so this is an opportunity to take a serious look at yourself in a systematic way. This questionnaire is not a test, and your participation in this process is completely voluntary and for your personal benefit. There are no foreseeable risks associated with this process. However, if you feel uncomfortable answering any questions, you may ignore individual questions or you can withdraw from the questionnaire at any point.
Your questionnaire responses will be strictly confidential and data from this process will be reported only to you or those authorized by you in writing. However, if you anticipate releasing this data to others, you should carefully consider the consequences. You can complete a separate questionnaire that you want to release to others. Your information will be coded and will remain confidential. If you have questions at any time about the questionnaire or the procedures, you may contact [email protected]
By checking the box below you certify that you are an adult over the age of 18 of sound mind and have never been diagnosed with any psychiatric disorder. You acknowledge that you are not under the care of a psychological or psychiatric care professional. You accept that Life Insights, LLC or its owners or employees incur no liability to you of any kind by allowing you to complete this questionnaire. You understand that Life Insights mentors are not licensed counselors or psychiatric professionals. You acknowledge that you and you alone are responsible for your actions or the consequences that might result from this process. If you choose to release data from this questionnaire to others, you accept full responsibility for the consequences and will hold Life Insights harmless.
DO NOT PROCEED WITH THIS QUESTIONNAIRE IF YOU ARE NOT IN COMPLETE AGREEMENT WITH THE STATEMENTS ABOVE OR ARE NOT EMOTIONALLY CAPABLE OF DEALING WITH ANY REACTIONS OR RESPONSES THAT MAY ARISE FROM OTHERS YOU DESIGNATE TO SEE YOUR RESPONSES !! THEIR REACTIONS ARE YOUR RESPONSIBILITY ONLY!!
Important Notice: The questionnaire format and its content are copyrighted, highly confidential and the proprietary property of Life Insights, LLC. They are not to be copied by anyone for any purpose.
Thank you very much for your time and interest. Please start by selecting the "I Agree" button below and then clicking on the Continue button below.
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2. Your Contact Information
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3. Please confirm your relationship to the person you are evaluating in this questionnaire? |
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| 4. Please enter your name | | | | Your birthplace | | | | Your birth nationality | | | | Your current nationality | | |
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5. Where were you in the birth order of your original family? |
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6. How would your rate your birth family/socioeconomic circumstances versus other people in your society? |
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7. How would you rate your childhood? Please comment briefly |
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8. How would you rate your childhood upbringing versus other people in your society? |
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9. Please rate the quality of the educational opportunities you had as a child. |
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10. Overall, rate your father as a parent. |
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11. Please describe your current relationship with your father. |
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12. Overall, rate your mother as a parent. |
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13. Please describe your current relationship with your mother. |
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14. How would you rate the affection you received from your parents as a child? |
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15. Were you physically abused a child? |
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16. Were you verbally or emotionally abused or neglected as a child? |
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17. How would you rate your intellect versus people in general in your society? |
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18. How would you rate your overall personal appearance versus others in your age group? |
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19. Overall and historically, how would you rate yourself as an athlete? |
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20. From an overall behavioral perspective, rate yourself as a child versus your peer group. |
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21. How would you rate yourself as a student? (past or present tense) |
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22. Please confirm your education level |
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23. Please rate your career achievement versus your age peers. |
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24. Please rate your overall career job income performance versus your age peers. |
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25. Please rate your current income performance versus your age peers. |
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26. How would you rate your current family/socio-economic circumstances versus other people in your society? |
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27. How would you rate your boss? |
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28. How would you rate your career versus your aspirations at this point? |
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29. How would you rate yourself as a financial provider now? |
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30. How would you rate your future career prospects? |
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31. How would you rate your current lifestyle versus your aspirations for your current age? |
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32. How do you rate yourself as an achiever versus your age peer group and your potential? |
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33. How would you rate yourself as a boss? |
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34. How would you rate yourself as an employee? |
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35. Is the future more of a problem or an opportunity for you? |
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36. Generally, how would you rate your happiness? |
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37. Overall, how would you rate your feelings about your future? |
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38. How much of your life potential have you achieved given your current age? |
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39. Overall, how would you rate your life experience to date? |
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40. How would you rate your general outlook? |
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41. How do you feel about America's future? |
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42. How would you rate yourself as a competitor? |
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43. How would you rate your breadth of knowledge versus your age group? |
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44. How would you rate your sense of style versus other people in your peer group? |
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45. Generally, how would you rate your tactfulness? |
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46. How persuasive are you? |
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47. How would you rate your charisma? |
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48. How reliable is your intuition? |
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49. How would you rate your sense of humor versus other people in general? |
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50. How would you rate yourself as a conversationalist? |
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51. How would you rate your overall social skills versus other people? |
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52. How well are you generally liked by other people? |
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53. How would you rate your self confidence versus your age peer group? |
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54. How would you rate yourself as a hard worker? |
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55. How would you rate yourself as a learner? |
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56. How would you rate your imagination? |
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57. How would you rate yourself as a listener? |
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58. How would you rate yourself as a writer? |
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59. How would you rate yourself as a reader? |
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60. How would you rate your overall personality versus other people? |
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61. How would you rate yourself as a leader? |
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62. How would you rate your level of curiosity/inquisitiveness? |
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63. How do you rate yourself as a follower versus a leader? |
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64. Are you generally reactive or proactive? |
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65. Overall, how do you rate your analytical/reasoning ability? |
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66. How do you rate your artistic ability? |
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67. How do you rate your musical abilities? |
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68. How do you rate your mathematics ability? |
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69. How do you rate your mechanical/engineering/scientific understanding ability? |
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70. How would you rate your business analytical abilities? |
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71. How would you rate your ability to change, adapt and grow? |
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72. How would you rate your ability to effectively prioritize things? |
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73. How would you rate your ability to focus on tasks assigned? |
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74. How would you rate your ability to innovate? |
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75. How would you rate your public speaking ability? |
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76. How would you rate your ability to intuitively sense other people's perspectives? |
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77. How would you rate your ability to express your thoughts and feeling verbally? |
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78. How would you rate your ability to productively multi-task? |
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79. Overall, how would you rate your ability to communicate? |
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80. How would you rate your ability to express your thoughts and feelings in writing? |
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81. How would you rate your ability to maintain your composure in stressful situations? |
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82. How would you rate your ability to make difficult decisions? |
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83. How would you rate your ability to overcome adversity? |
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84. How would you rate your ability to get things done in a timely fashion? |
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85. How would you rate your internet and computer literacy versus your age group? |
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86. How much international travel have you experienced versus your age group? |
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87. How would you rate your knowledge of history versus other people? |
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88. How do you rate your knowledge of politics and government versus other people? |
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89. How much do you follow global events? |
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90. How would you rate your "Common Sense"? |
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91. How would you rate your ability to see "The Big Picture" of situations? |
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92. How well would you rate your ability to see "The Big Picture" of life? |
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93. How easy is it for you to admit when you have been wrong about something & apologize if appropriate? |
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94. How would you rate your emotional health and stability versus other people in general? |
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95. How do you react to constructive criticism? |
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96. How would you rate your ability to control your temper? |
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97. How do you act when you are very angry with someone? |
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98. How often do you get very angry or hostile toward someone? |
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99. How motivated and goal oriented are you versus your peer group? |
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100. Overall, how open minded are you? |
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101. Given a choice, would you rather be right or happy and successful? |
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102. How would you rate your self-esteem? |
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103. How would your rate your decisiveness? |
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104. How well do you take responsibility for your own happiness? |
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105. How well do you take responsibility for your own life? |
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106. Are you generally on time? |
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107. Overall, how would you rate your reliability? |
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108. How well do you function when you are alone in your life? |
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109. How would you rate your housekeeping habits? |
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110. How would you rate your emotional maturity level versus your age peer group? |
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111. How would you rate your patience overall? |
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112. How do you rate yourself on stubborn versus flexible? |
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113. How well do you manage stress? |
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114. How would you rate your level of self-discipline? |
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115. How do you rate your ability to make and keep quality friendships. |
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116. How do you think and make decisions? |
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117. How would you rate your level of self-motivation? |
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118. Overall, are you more dependent or independent? |
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119. Overall, how organized are you? |
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120. How set in your ways are you? |
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121. Overall, are you more lazy or energetic? |
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122. How motivated are you to excel and achieve versus your peer age group? |
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123. Generally, are you more inclined to make excuses or get results? |
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124. How important is your ability to make good choices to your success in life? |
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125. How important is your ability to compete to success in your life? |
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126. How would you rate your personal life judgment overall? |
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127. How would you rate your professional judgment versus your age peer group? |
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128. Overall, how would you rate your ability to judge people accurately? |
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129. How would you rate your financial judgment overall? |
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130. How would you rate your overall personal judgment with friends in your life? |
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131. How would you rate your overall personal judgment with significant others in your life to date? |
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132. How would you rate your physical health versus your age group peers? |
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133. How would you rate your current weight for your age group? |
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134. What is your current status and marital history? |
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135. How many adopted or step-children do you have? |
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136. How many biological children do you have? |
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137. Rate yourself as a parent. If no children or step-children select 0. |
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138. How would you rate your overall character versus other people in general? |
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139. How would you rate your personal courage level overall? |
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140. How would you rate your trustworthiness versus people in general? |
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141. How would you rate your conscience? |
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142. How would you rate your honesty and integrity overall? |
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143. Overall, how would you rate your generosity? |
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144. Overall, how would you rate your compassion and empathy for others? |
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145. Overall, how well can you be counted on by others? |
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146. How would you rate your willingness to help others? |
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147. How do you rate yourself on selfless versus selfish? |
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148. Overall, how would you rate yourself as a friend? |
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149. Is your anger/temper an issue in your life? |
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150. Is your alcohol consumption an issue in your life? If so, please describe briefly. |
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151. Is your non-alcohol substance abuse an issue in your life? If so, please describe briefly. |
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152. Have you had any DWI's or DUI's? If so, please describe briefly. |
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153. Is your physical abuse of anyone an issue in your life? |
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154. Have you ever physically harmed someone in your life except in self-defense? If so, please describe briefly |
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155. Is your verbal or emotional abuse of anyone an issue in your life? |
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156. Have you been physically abused? If so, please describe briefly. |
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157. Have you been verbally or emotionally abused? If so, please describe briefly. |
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158. Is your gambling an issue in your life? |
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159. Is someone else's gambling an issue in your life? If so, please describe briefly.
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160. Has your breaking of laws been an issue in your life? If so, please describe briefly.
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161. Has someone else's law breaking been an issue in your life? |
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162. Is your reckless spending an issue in your life? If so, please describe briefly. |
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163. Is someone else's reckless spending an issue in your life? |
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164. Is your unemployment an issue in your life? |
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165. Is someone else's unemployment an issue in your life? |
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166. Has your infidelity been an issue in your life? If so, briefly describe. |
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167. Has someone else's infidelity been an issue in your life? If so, please describe briefly. |
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168. Is your dishonesty or untrustworthiness an issue in your life? |
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169. Is someone else's dishonesty or untrustworthiness an issue in your life? |
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170. How do you feel about tattoos on you? |
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171. Please check any issues below that apply to you even if they are infrequent.
The goal is to identify issues to be addressed so be completely honest with yourself.
Note: Select the answers & Other if you want to add other issues |
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172. Are there things in your past that are adversely affecting your life today? |
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173. Are there significant fear factors that affect your life? |
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174. How would you rate yourself as a life partner? |
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175. How would you rate yourself as a lover? |
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176. How would you rate yourself as a friend to your spouse or significant other? If no spouse or significant other now, please refer to your last previous relationship. |
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177. How would you rate yourself as a social asset to a spouse or significant other? |
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178. How would you rate yourself as a professional asset for a spouse or significant other? |
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179. How would you rate yourself on affection and intimacy with a spouse or significant other? |
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180. How would you rate yourself on trustworthiness with a spouse or significant other? |
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181. How would you rate your general willingness to compromise in relationships? |
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182. How would you rate your willingness to consistently place your relationship with your spouse or significant above other concerns? If no spouse or significant other now, refer to your last previous relationship. |
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183. How would you rate your willingness to apologize and seek reconciliation after conflict? |
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184. How would you rate your willingness to let go of resentments? |
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185. Please rate your willingness to express your true thoughts and feelings and communicate with your spouse or significant other? If no spouse or significant other now, refer to your last previous relationship. |
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186. Rate your ability to offer positive solutions to issues with your spouse or significant other and work to achieve permanent solutions. If no spouse or significant other now, refer to your last previous relationship. |
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187. How would you rate your overall common interests and shared life priorities with your spouse or significant other? If no spouse or significant other now, refer to your last previous relationship. |
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188. Rate how good you are at consistently making your relationship with a your significant other a top priority and honoring your commitments to them. If no spouse or significant other now, refer to your last previous relationship. |
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189. Rate how reliable a source of support you are for your spouse or significant other. If no spouse or significant other now, refer to your last previous relationship. |
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190. Rate how compatible your and your spouse or significant other's views of parenting are. If no spouse or significant other now, refer to your last previous relationship. |
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191. Overall, rate your compatibility with your spouse/significant other. If no spouse or significant other now, refer to your last previous relationship. |
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192. Is sex a problem in your relationship with your spouse or significant other? If no spouse or significant other now, refer to your last previous relationship. |
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193. How important is a good relationship with a spouse or significant other to your happiness? |
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194. How would you describe your romantic nature? |
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195. Where is sex on your list of priorities? Select more than 1 choice if applicable. |
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196. Please rate your personal happiness among your overall life priorities. |
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197. Please rate your significant other's happiness among your overall life priorities. |
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198. Please rate your relationship with your spouse or significant other among your life priorities. |
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199. Please rate your children's happiness among your overall life priorities at his point in your lives. |
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200. Please rate your career among your overall life priorities. |
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201. Please rate material things among your life priorities. |
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202. Please rate friends among your life priorities. |
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203. Most people have elements of more than one personality profile so please select the personality traits that apply to you to some degree.
Then rate the items you chose with a percentage that applies to you for each choice you made to reach a total of 100% for all traits. |
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A. Type “A” Personality - Leaders - Entrepreneurial, risk takers, direct, innovative, self-motivated, dislike routine, enjoy change, focused, decisive, persistent, and can be insensitive and impatient. Socially functional because it is a necessity to reach their ambitions, but can turn off other people. Rely on their intellect, leadership qualities and knowledge to succeed. Achieving success is very important.
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B. Type “B” Personality - Socially oriented – Love excitement and to party and travel, enjoy groups, like being center of attention, supportive of friends, want to be liked by others and easily hurt if rejected, good public speakers, talkative, personable, persuasive, outgoing extroverts. Rely more on their personalities than their expertise to succeed. Tend to think more emotionally than rationally. Enjoying life is very important.
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C. Type "C" Personality - Artistic and creative oriented - Usually fashionable or flaky dressers. Enjoy expressing their active imaginations through writing or other artistic expression. Socially interesting but can be reserved. Tend to think more emotionally than rationally. Often have difficulty with analytical thinking and mathematics. Rely on their artistic talents to succeed. Expressing themselves through their art is very important.
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D. Type “D” Personality - Detail and analytically oriented – Precise, organized, consistent, predictable, responsible, thoughtful, slow to make decisions, emotionally sensitive, inquisitive, loyal, and patient. Think more rationally than emotionally. Rely on their expertise to succeed. Can struggle in social settings. Understanding the details is very important.
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E. Type “E” Personality - Status quo lovers – Dislike change, prefer the predictable, enjoy repetitive tasks, security oriented, compassionate of others, happy, punctual and content. Rely on consistent conformity to succeed. Preparing for a great retirement is very important.
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F. Type “F” Personality - Underachievers – Can be very bright, but low self-esteem and/or motivation are obstacles to their life potential. Inward focused and prefer to settle for less in life rather than to aspire for more and have to face the potential for failure. Rely on low self-expectations to avoid dealing with success. Avoiding competition and accountability is very important.
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G. Type “G” Personality - Self destructive – Reject societal expectations, and engage in self-destructive behavior without concern for the adverse effects on their life potential. Every problem they have is someone else’s fault. Success is being a non-conformist. Doing whatever they want is very important.
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List a percentage of each personality type that applies to you to total 100%:
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204. Where would you rate yourself on the political spectrum? |
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205. How concerned are you about political outcomes in 2012? |
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| 206. Comments/Suggestions: | | |
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| 207. Please release this completed questionnaire to the following person(s) at the listed e-mail address(es): | | |
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