Life Issues Assessment  

Completion of this assessment form is designed to give you an idea of some of the life issues that can be addressed during the Authentic Life process.  Please rate the following issues on a scale of 1-5 in terms of how much you struggle with each of them.   [Printable form]
(5 = constantly struggle with this issue;   1 = never struggle with this issue.)

____ Fear of failure
____ Fear of success
____ Procrastination
____ Perfectionism
____ Development of rapport with others
____ Negative self image
____ Time management and organizational skills
____ Integration of professional and personal life
____ Lack of assertiveness
____ Stagnation in overly comfortable activities or thought patterns
____ Low self-confidence
____ Fear of conflict and/or confrontation
____ Confusion about career choices
____ Discomfort with physical appearance and/or style of speech
____ Expression of anger (either non-existent or exaggerated)
____ Fear of speaking in public
____ Poor sense of personal boundaries
____ Limited or non-existent capacity to dream about the future
____ Addictive tendencies (abusive relationships, food, drugs, cigarettes, alcohol, spending, etc.)
____ Other (please explain)_________________________________________

Save your responses. If your score for any issue is 3 or more, you may experience transformation by focusing on this life element during the Authentic Life process. If you'd like to discuss the above issues with Ellen Antill during your complimentary consultation, print a copy of this completed form for your records and also email it to Ellen for her review prior to your consultation.

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