Name: _________________________ Sex:
_____ Date: _______________
Finding my Purpose
1. My childhood dream is: _____________________________________________
2. My dream now is:
__________________________________________________
3. My saving grace in childhood (personal characteristic
- example: artistic ability, sense of humor, sensitivity, etc.): _____________________________________________
4. My saving grace now is: ____________________________________________
5. Something I remember that makes me happy of feel
strong is: _________________
___________________________________________________________________
6. Three things that are the most important to me are:
_________________________
___________________________________________________________________
7.
My roles in life that matter to me are (son or daughter, friend, brother or sister, individual, student, etc.):
______________________________________________
___________________________________________________________________
8. What matters to me in each of my roles (help my sister
with her homework, to do my homework as a student, etc.): ___________________________________________
___________________________________________________________________
9. My favorite childhood story or fairy tale was:
_____________________________
10.
Who or what I most identified with in the childhood story or fairy tale was: ______
___________________________________________________________________
Finding Better Ways to Cope
1. As a child, when I was sad or upset I turned to:
A parent_____A sibling_____A peer_____A teacher_____A grandparent_____
A neighbor_____Family Friend_____Member of my religious faith_____
Kept to myself_____The family pet_____A toy or object_____T.V._____Other______(Circle the above items you turn to now)
2. Before 16, I felt the most comfort from involvement with:
People_____Animals_____Nature_____God_____Art_____Reading_____ Dance_____Music_____Writing_____Athletics_____Other____________________
(Circle the above items you feel the most comfort from now)
3. When I was a child, I most wanted to grow up and be like: ___________________
___________________________________________________________________
4. Why? (person you knew or knew through books, etc.):
______________________
___________________________________________________________________
5. The person I most want to be like now is: ________________________________
Why?: ____________________________________________________________
6. What do I turn to, to laugh or get in a better mood?:
________________________
___________________________________________________________________
7. What music do I turn to, to get a lift?: ___________________________________
___________________________________________________________________
8. How do I focus my energy, compassion or care for others?:
__________________
___________________________________________________________________
9. The activity that brings me the most satisfaction and happiness is:
_____________
___________________________________________________________________
10. What I want written on my epitaph is:
__________________________________
___________________________________________________________________
Skills I Need to Survive and Thrive
Rate each of the following on a 1-10 scale with 10 high and 1 low
1. I would rate my ability to cope with my stress as a: _________________________
To cope with stress I: ________________________________________________
2. I would rate my ability to control my anger as a:
___________________________
To cope with anger I: _________________________________________________
3. I would rate my ability
to relate to others as a: _____________________________
My closest friends are (What are these friends like?): ________________________
___________________________________________________________________
4. I would rate my ability to identify and express my feelings as a:
________________
What feelings are hardest to be assertive with? _____________________________
___________________________________________________________________
5. I would rate my ability to assert what is important to me as a:
_________________
What people are hardest to be assertive with?________________________________
___________________________________________________________________
6. I would rate my ability to manage my moods (such as depression) as a:
__________
The situations or people with which I have the most difficulty managing my emotions are:
______________________________________________________________
___________________________________________________________________
7. I would rate my ability to renew, nurture, and make myself feel stronger
as a: ______
___________________________________________________________________
When I need to nurture myself I: ________________________________________
___________________________________________________________________
8. I would rate my ability to deal with hard situations as a:
_____________________
My childhood survival skills are___________________________________________
My survival skills
that I rely most on now are: ______________________________
9. I would rate my ability to use my hands to create and do rewarding things as
a: ___
___________________________________________________________________
The things I like to do with my hands are: _________________________________
10. I would rate my ability to learn new things as a: ___________________________
The most recent new things I have learned are: _____________________________
___________________________________________________________________
Some new things I would like to learn are: _________________________________
___________________________________________________________________
My Personal Interests and Pleasures (Please check those you enjoy or have enjoyed)
_____Acting in a play _____Bedtime stories
_____Bicycle riding
_____Bird watching _____Blowing
bubbles _____Carving
_____Climbing a tree _____Coloring books
_____Comic books
_____Creeks or rivers _____Doodling
_____Feeding birds
_____Fishing
_____Flying a kite
_____Going barefoot
_____Going for a drive _____Going to the zoo
_____Grandfather clocks
_____Having a collection _____Hiking
_____Hopskotch
_____Horseback riding _____Ice skating
_____Jogging/running
_____Jumping rope _____Karate/judo/aikido
_____Lakes or reservoirs
_____Listening to music _____Lying in a hammock
_____Making a sculpture
_____Meditation
_____Movies
_____Painting/sketching
_____Pets
_____Picnics
_____Ping pong
_____Playing sports _____Playing checkers
_____Playing chess
_____Playing darts _____Playing
football _____Playing hide and seek
_____Playing horseshoes _____Playing in a hideout _____Playing
in the sprinklers
_____Playing marbles _____Playing an instrument
_____Playing with a puppet
_____Playing in a wagon _____Playing with a baby _____Playing
with dolls
_____Playing with jacks _____Playing with toy cars _____Playing
with toy soldiers
_____Pool/billiards _____Porch swings
_____Pottery making
_____Quilt making _____Rafting on a river
_____Raising flowers
_____Reading
_____Recess during school _____Rocking chairs
_____Sand pile play _____Sauna
_____Sculpting in clay
_____Security blanket _____Singing
_____Sitting in front of a fire
_____Sitting in yard _____Skateboarding/skating _____Sleeping
in late
_____Sleigh riding _____Slippy slide
_____Snowmobile riding
_____Snowball fight _____Solving puzzles _____Stuffed
animals
_____Sunbathing _____Surfing
_____Swimming
_____Swing sets _____Symphony concerts
_____Taking a nap
_____Television _____Tennis
_____Thanksgiving day
