——————————— Life Review ———————————
Life Review
Directions:
Complete this document, save a copy and email as an attachment to
Name:Address:
City: / State: / Zip:
Home Phone: / Office Phone:
Fax: / Email:
NOTES/COMMENTS
PLEASE NOTE: If completing on your computer, please enter your response inside the boxes. Each box will automatically expand as you type to accommodate your answer. If you are filling it out by hand, please use additional paper if necessary.
PERSONAL DEVELOPMENT– HISTORY –
Birthplace:
Where did you grow up?
– SCHOOLING –
1.
/What kind of student were you, academically and socially, in:
/Elementary School:
/High School:
/College:
/Other:
2.
/Did you like going to school? Please explain:
3.
/How well did you get along with your classmates?
//
With your teachers?
/4.
/What kind of extracurricular activities did you enjoy participating in?
/5.
/What kind of music did you listen to?
/6.
/What was your favorite hangout place?
/7. / What age stands out in your mind?
/
Why?
/ADULT YEARS
1.
/How much TV do you watch per week?
/2.
/List three movies that had an impact on your life. Explain what impact that was:
/1:
/2:
/3:
3.
/How is technology affecting your life experience?
/4.
/When was the happiest time in your life, ever?
/5.
/List four values that are very important for you to live by:
/1:
/2:
/3:
/4:
6.
/Describe any experience you’ve had using the following personal skills:
/SKILL
/ /THE EXPERIENCE
/Personal Achievement:
/ //
Creativity:
/ //
Dealing with Change:
/ //
Open-mindedness:
/ //
Taking Personal Time:
/ //
Handling Failure:
/ //
Being Non-judgmental:
/ //
Helping Others:
/ //
Leadership:
/ //
Public Speaking:
/ //
Cooperation/Teamwork:
/ //
Confronting/Challenging:
/ //
Risk Taking
/ //
Imagination/Intuition
/ /7. / Have you ever been addicted to anything?
/
If so, and you were able to overcome it, explain how you did this:
/8.
/List your current five top priorities, in order of importance:
/1:
/2:
/3:
/4:
/5:
/How does this list differ from what you would have said five years ago? Ten years ago?
/9.
/List any talents/gifts you embody, and how you are currently using/sharing them:
/10.
/What talents of yours do you feel you are currently not expressing or could be expressing more?
/11. / How effective are you at managing time?
/
Explain:
/12.
/How important to you is your physical appearance?
/13.
/Do you have a professional wardrobe?
/14.
/Do you journal or listen to motivational tapes/CDs?
/15. / Are you currently attending, or have you attended, any workshops or seminars?
/
If so, describe what you have taken, and why you believe that has helped you be more of the person you want to be.
/16.
/What would you describe to be your greatest achievement?
/COMMUNITY
1.
/How involved were your parents in religious/community activities when you were a child?
/2. / Did you do any kind of volunteer work as a child?
/
Explain:
/3. / When you were a teenager, did you do any kind of volunteer work?
/
Explain:
/4.
/Describe the atmosphere of the neighborhood where you grew up:
/5. / Was there any political cause that your family ever championed?
/
If yes, explain:
/6.
/Were your parents leaders in the community in any way?
/7. / Are you currently involved in any kind of volunteer work?
/
If so, describe:
/8.
/Do you have any strong political affiliations?
/9. / On a scale of 1-10, rate yourself as being a good steward of the environment.
10.
/Are you involved in any social organizations?
/11. / Do you watch the news?
/
Either way, how else are you aware of what is happening on the planet each day?
/12. / Do you think it’s important to know what is going on in your state, country and
/
planet?
//
Why or why not?
/13. / Do you regularly attend Religious services?
/
Why or why not?
/14. / Do you contribute to social causes or organizations?
15. / Do you currently socialize with people in your neighborhood?
/
Explain:
/16.
/Do you have any concerns or worries about your community or your community involvement?
/CAREER/PROFESSION
1.
/List any job you’ve had that you feel made an important contribution to who you are today:
/POSITION
/ /QUALITIES DEVELOPED
2.
/Describe your present career position:
/3.
/What do you like most about your current job?
/4.
/What do you like least about it?
/5. / Do you prefer working by yourself or with others?
/
Explain:
/6. / Are you content with the amount of money you make in your job?
7. / Do you often feel stressed on the job?
/
Explain when:
/8. / Do you tend to be a workaholic?
9.
/What do you feel are/were the primary benefits of your current/most recent job?
/10. / On a scale of 1-10, how fulfilled are/were you in your current/most recent job?
/
Explain:
/11.
/When you were a child, what did you dream about becoming when you grew up?
/Are you living any of that dream today?
/
Explain:
/12.
/How successful have you been in expressing your gifts/talents on the job? Explain:
/13.
/Put an “X” next to each of the below skills in which you feel you excel.
/Delegating / Organizing / Supporting Others
Encouraging / Decision Making / Adaptability
Writing / Self-reviewing / Budgeting
Selling / Planning / Motivating
Evaluation / Public Speaking / Teaching
Persuading / Negotiating / Time Management
14. / What was the BEST JOB you ever had?
/
Explain:
/15. / What was the WORST JOB you ever had?
/
Explain:
/16.
/What has been the greatest contribution you have ever made in a work environment?
17. / If someone gave you ten million dollars, would you still work?/
If so, what would you do?
//
If not, what would you do?
/FAMILY
1.
/Describe your impression of your childhood experience:
2.
/Growing up, what was your relationship like with your father?
/Growing up, what was your relationship like with your mother?
/Growing up, what was your relationship like with your siblings (if applicable)?
3.
/Describe your current relationships with your parents. (If deceased, describe your relationship with that parent before they passed on.):
4.
/Describe your current relationships with your siblings (if applicable):
5.
/What childhood memories give you the greatest satisfaction?
6.
/How supportive were the members of your family in helping each other?
7.
/What did you wish was different when you were growing up?
8.
/When you were a child, what kind of family did you dream about having when you were grown up?
9.
/Describe your current family life:
(If you are not a parent, skip questions 11-27)
10.
/How effective are your parenting skills?
11.
/How effective do you feel as a parent?
12.
/How much do you rely on the other members of your family to assist in running your household?
13.
/How would you describe the overall attitude/atmosphere in your home?
14.
/How active are you in keeping order in your home?
15.
/Are you aware of any stereotypical roles happening in your family life? (ex. woman takes care of kids & cleans while man makes the money)
/How do you feel about these roles?
16.
/Did you grow up in a stereotypical household?
17.
/How well do you relate to your children?
18.
/Do you feel you have a good understanding of your children’s developmental process?
19.
/How much time do you spend with your children each day?
20.
/What is your favorite family get-together?
21.
/On a scale of 1-10, rate your current satisfaction with your experience of “family.”
22.
/What are the greatest benefits you receive from being part of a family?
23.
/What are the greatest challenges?
24. / Have you dealt with grown children “leaving the nest”?/
If so, how?
/25. / Are any of your children challenged in anyway?
/
If yes, please describe what the challenge is and how it is affecting your role in the family.
/26.
/What is the greatest concern you have regarding your family?
INTIMATE & SOCIAL RELATIONSHIPSSOCIAL
1.
/How easy was it for you to make friends when you were a child?
2.
/List two childhood friends and tell something about them.
3.
/How much did you enjoy being with your friends?
4. / Did you participate on any group activities?/
Describe the experiences:
/5.
/Were you encouraged by your parents to make new friends?
6. / Did you ever feel isolated from others?/
If so, explain how you dealt with it.
/7.
/Currently, how many of your close friends are friends you’ve had for more than five years?
8.
/Do you consider yourself to be an introvert or an extrovert?
9. / What has been the most significant friendship you have experienced so far in this life?/
Why?
/10.
/What are the qualities you look for in a friend?
11. / On a scale of 1-10, rate yourself on being a good friend./
Explain:
/– SINGLES ( if applicable) –
1.
/How fulfilled are you with your present close friendships?
2. / Is it important to you to find a life partner?/
Explain:
/3. / Is loneliness an issue for you?
/
If so, explain how you deal with it:
/– MARRIED or WITH PARTNER ( if applicable) –
1. / How old were you when you got married? (If applicable)2.
/How close are the expectations you had about marriage/relationships being played out in your current situation?
3. / Is your relationship thriving?/
Explain:
/4. / Is there any co-dependency in your relationship?
/
If so, describe:
/5. / Is your partner supportive of the REAL YOU?
Are you supportive of your partner?
6.
/Is there any enabling going on in your relationship?
7.
/What is the greatest thing about being married/being with a partner?
8.
/What do you enjoy most about your partner?
9.
/What is your greatest challenge?
10.
/List 3 activities you really enjoy sharing with your partner:
/1:
/2:
/3:
11.
/What are the themes of most your quarrels or disagreements?
12.
/At the end of a disagreement, how do you usually feel?
13.
/How does your partner usually feel?
14.
/How fulfilled are you in your sex life?
15. / Have you ever felt your trust to be violated?/
Explain:
/16. / On a scale of 1-10, 10 being the best, how would you rate your relationship?
How do you think your partner would rate it?
/
What does this tell you?
17.
/What is the greatest concern you have regarding your intimate relationship?
CULTURE
1.
/How comfortable do you feel with people who have a different economic background? (Rate 1-10, 10 being totally comfortable.)
Economic Background?Religion?
Culture?
Sexual Preference?
Political Party?
Educational Background?
2.
/Do you have good friends with different: (Rate 1-10, 10 being totally comfortable.)
Economic Background?Religion?
Culture?
Sexual Preference?
Political Party?
Educational Background?
HEALTH/AGING
2. / Do you have any physical challenges?
/
If so, describe how they impact your life:
/3.
/Do you get enough sleep to feel refreshed each day?
4.
/Is your daily energy level sufficient to do all the things you desire to do?
5. / How active were you as a child? / How active are you now?/
Describe:
/6. / Do you have an exercise program?
/
If so, describe:
/7.
/Growing up, describe your typical diet:
8.
/Describe your current eating rituals/habits:
9.
/What message did your parents give you about food?
10.
/Were you ever rewarded with food?
11.
/How healthy were your parents?
12. / Did they smoke? / Do you? / If so, how much?13. / Did they drink? / Do you? / If so, how much?
14. / Did you regularly see a doctor/dentist?
15. / Do you take supplements/vitamins?
16. / Have you experienced someone close to you dying?
/
Explain:
/17. / Are you content with your current age?
18.