Please rate yourself on a 1-to-10 scale. On the line __, please rate where you
currently are, and in the brackets [___], please rate where you would like to
be.
, [ ] 1. How much self-confidence I have
, [ ] 2. How well I'm doing in school based on my full potential
, [ ] 3. How well I'm doing in the area of friendship
, [ ] 4. My relationship with my parents
, [ ] 5. Achieving my full potential in all areas of my life.
Name:
E-mail:
Someone you'd like to refer: (5 points):
This person's e-mail:
Someone else you'd like to refer: (2 points):
This person's e-mail:
Your birthday: //
Nickname:
* Please rate which of the following four shapes in the order in which you like
them most (1 for your favorite, 2 for your second favorite, etc.):
a. Cube
b. Pyramid
c. Wavy Lline
d. Ball
* Which one of the following would cause you the most stress in any area of
life:
a. Things not being done right.
b. Things being out of control
c. Things being boring
d. Conflict with other people
* How many brothers and sisters do you have, and where do you fit in the birth
order (ie. you would put 2of4 if you are the second of four)?
* What are the two biggest challenges you're currently facing in any area of
your life?
Please check the following areas in which you
would be interested in receiving additional information.
A. Periodic suggestions, tips, articles, and links to web sites that could
help you achieve your full potential
B. Tips on making and keeping friends
C. Tips on being a strong leader
D. Tips on overcoming peer pressure
E. Tips to helping me understand and communicate with my parents
F. Information on completing a Life X-Ray (analysis of your strengths and
weaknesses, your personality, etc.)
G. Information on how to achieve my full potential through goal setting
H. E-mail suggestions to my parents so they can understand certain
personality types and receive parenting tips.
Parent's (or parents') name(s):
Parent's (or parents') e-mail address: