Birthdate: Month/Day/Year

Date: Name: Phone Number: Email Address: Birthdate: Month/Day/Year

To receive a complimentary 30 minute Activation of Possibility Session: 1. Answer these questions on this form 2. Return the completed form to [email protected] 3. Book your session here: BarbarasCalendar.com

A. Mark the letter next to the group of four words that most closely describe who you are. B- Logic, Results, Structure, Analysis G- Order, Routine, Process, Procedures Y- Vision, Creativity, Imagination, Expression R- Empathy, Promotor, Harmony, Action

B. Answer these questions. Simply a yes or no is fine. If you’d like to write more that’s fine too.

1. Are you generally uneasy about what people expect of you?

2. When you make a mistake is it difficult for you to forgive yourself?

3. Do you sometimes call yourself names like "stupid" or "loser"?

4 Do you worry that you're going to screw up?

5. Do you often wonder if others are evaluating you?

6. Do you fee it is too hard to get what you want in life?

C. What are your Ten Defining Moments?

In every person's life, there have been moments, both positive and negative, that have defined and redefined who you are. Those events entered your consciousness with such power that they changed the very core of who and what you thought you were. A part of you was

Barbara Robins www.healingisfun.com 847-566-6559 changed by those events, and caused you to define yourself, to some degree by your experience of that event.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

D. What are your Seven Critical Choices?

There are a surprisingly small number of choices that rise to the level of life-changing ones. Critical choices are those that have changed your life, positively or negatively, and are major factors in determining who and what you will become. They are the choices that have affected your life up to today, and have set you on a path.

1. 2. 3. 4. 5. 6. 7.

E. Who are your Five Pivotal People? What reason are they pivotal?

These are the people who have left indelible impressions on your concept of self, and therefore, the life you live. They may be family members, friends or co-workers, and their influences can be either positive or negative. They are people who can determine whether you live consistently with your authentic self, or instead live a counterfeit life controlled by a fictional self that has crowded out who you really are.

Barbara Robins www.healingisfun.com 847-566-6559 1. 2. 3. 4. 5.

F. 10 Crucial Questions Your Doctor Should Ask You (But Probably Doesn’t)

1.What is your body saying no to?

2.What does your body need in order to heal?

3.What’s out of balance in your life?

4.Do you feel like you’re in touch with your life’s purpose?

5.Are you lonely?

6.Do you feel sexually satisfied?

7.Do you feel depressed, anxious, or frequently afraid?

8.Are you an optimist or a pessimist?

9.Do you often feel helpless?

10. Do you believe in a Higher Power?

G. Looking at the Future

1. How committed are you to improving your life? Strongly Disagree Strongly Agree 1 ------5 ------10

2. How strongly do you believe your life can improve? Strongly Disagree Strongly Agree 1 ------5 ------10

3. What are your priority challenges you would like to work on in the coming three months? List up to three.

Barbara Robins www.healingisfun.com 847-566-6559