COPYRIGHT 2017 SCOTTANTHONY.COM Page 1 of 8 · The relationship I have with my father now is: _____ ... The memories I have of my teachers encouraging me are: Lots, Seldom, None,

Where we are or where we are going, is often a result of where we have come from.

Our mind also hears the voices of our parents and peers who have shaped our influences and ultimately helped create the visions we have of ourselves.

Sounds SIMPLE… but, since your very young years of 4 to 7, your belief structure has either been starved or nourished.

These following questions are private and for your eyes only.

They should be kept in a safe place and answers with honest openness with yourself.

The questions are designed to be difficult and they are designed to be revealing. Many of us have had both happy or unhappy childhoods … and understanding the foundations of

our early years, helps us understand the patterns we form as young adults.

Discovering thee habits and the practices we have used to get us to where we are today is a fundamental KEY to knowing what we can each change to move us into new patterns

and choices that can bring about he changes we want in our lives .

We will now go deep inside to discover true feelings about what we felt growing up and how it has shaped our lives this far.

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PARENTS / GUARDIANS

The relationship I had with my father was: _________________________________________

It would make me feel __________________________________________________________

The relationship I have with my father now is: ______________________________________

It makes me feel ______________________________________________________________

The relationship I had with my stepfather was: _____________________________________


The relationship I have with my stepfather is: ______________________________________

It makes me feel ______________________________________________________________

The memories I have with my stepfather encouraging me are: Often / Few / Rarely / Never


The memories I have with my stepfather criticizing me are: Often / Few / Rarely / Never




The relationship I had with my mother was: ________________________________________


The relationship I have with my mother now is: _____________________________________

It makes me feel ______________________________________________________________

The relationship I had with my stepmother was: ___________________________________


The relationship I have with my stepmother now is: _________________________________

It makes me feel __________________________________________________________

The memories I have of my stepmother encouraging me are: Often / Few / Rarely / Never


The memories I have with my step mother criticizing me are: Often / Few / Rarely / Never




(circle the one you agree with) The memories I have of my teachers encouraging me are: Lots, Seldom, None, Never Ever

The memories I have of my teachers makes me feel like they __________________ me.

My friends always used to call me: _______________________________________________

(circle the ones you agree with) My friends now think I am: Happy, Sad, Frustrated, Ambitious, Restless, Annoying, Intense, Dedicated, Disciplined, Calm, On edge, Excited, Happy, Unhappy, Loved, Kind, Caring, Selfish, Considerate, Un-loved, Shy, Reserved, Nervous, Anxious, Doubtful, Negative, Positive, Ready to Go or Hesitant to try new things.

My friends describe me as: _____________________________________________

My work colleagues would describe me as: _______________________________________

I would describe myself as __________________ at work.

My partner would describe me in 3 words as: 1. _________________________ 2. _________________________ 3. _________________________

My kids would describe me in three words as: 1. _________________________ 2. _________________________ 3. _________________________



My boss would describe me as a:_________________________________________________

My confidence is important to be at a level of ____/10.

My health is important to me at a level of ____/10. I am happy with my current weight ____/10

My fitness I would rate as ____/10

I am happy with the way I balance my work / life performance ____/10.

My family think I am ‘around’ enough as opposed to working all the time ____/10.

My family would say that I am their: _________________________________

I often find myself ______________________________________ when things get frustrating.

I tend to ________________________________ when I am tired.

I get ______________________ when I have an idea.

I feel ____________________________________ when things fall into place and go right.

I find myself _____________________________________ when other people doubt me.

I feel as if _________________________________ when I run out of time to get things done.



The consequences of not getting my health in balance is _____________________________

My plan is to ________________ my time management and create a better balance.

The one thing I remember people telling me as a child is _____________________________ The one thing I was good at as a child was ________________________________________

As an adult I now feel like I was empowered or held back as a child ___________________

As an adult I wish I had more ____________________________________________________

As a child I loved to ____________________________________________________________

When I was a teenager I used to Love ____________________________________________


When I was in school I used to love ______________________________________________


When I was in school I used to hate ______________________________________________


Growing up the relationship I had as a child with my brothers and sisters was ___________ _____________________________________________________________________________



As an adult I feel _________________________________ about my siblings.

I wish we _____________________________________________________________________

I am glad we __________________________________________________________________ I remember ___________________________________________ with my ________________

I wish we could ________________________________________________________________

I want my kids to be ______________________________________ with their siblings.

I want my kids to ______________________ me.

I want my kids to think I am ____________________________________________________

I want my kids to always remember how much I ___________________________________

I want to be remembered as a __________________________________________________

… who ______________________________________________________________________

My family is important to me because ___________________________________________

Those who know me best would say that my ____________________ comes first.



My best moments of my life so far are 1. ________________________________________________________________________

2. ________________________________________________________________________

3. _______________________________________________________________________

4. ________________________________________________________________________

5. ________________________________________________________________________

If I had one Month to live I would : 1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

5. ________________________________________________________________________

If I could start my life over again I would do some things differently.

List 5 things you would change if you could turn back time.

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

5. ________________________________________________________________________



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COPYRIGHT 2017 SCOTTANTHONY.COM Page 1 of 8 · The relationship I have with my father now is: _____ ... The memories I have of my teachers encouraging me are: Lots, Seldom, None,