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Psychological  Evaluation

This information is critical.  The more truthful you are on this information, the better program we can build for you!  

Please take your time with this completely confidential form!

 

Name:

Email:

Phone:

   

List your favorite and least favorite of the following:

 

Favorite

Least Favorite

Color:  

Number:

Season of the year:

Scent:

Texture:

Food:

Drink:

Feeling:

Exercise:

Weight Lifting Exercise:

Body Part to Work Out:

Sport:

Musical instrument to listen to:

Style of Music:

 

The best?

The least?

Which body part or physical feature of yours, do you like the best?  The least?


What part of your body is the most flexible / least flexible?

Most Flexible         Least Flexible
       

 

 


Do you have any extreme fears or phobias?


If you could only see one or the other for the rest of your life, not both, which would it be?

 Sunrise         Sunset


If you had to choose between living in an extremely cold or hot environment, which would you choose?

 Hot                 Cold


If you could physically visit any time in history for one year, which time period would it be & why?


If you could have one super power, what would it be?  (The only limitiation to this question will be in your own mind!)


If you could have three wishes, excluding, a wish for more wishes & some one to fall in love with you, what would your three wishes be?


Wish one:
Wish two:  
Wish three:  


(18 years of age or older)
If you were going to be driving a car on a road trip for more than 10 hours, and the car was only half full of fuel before you started the trip, would you fill up the fuel tank at the start of your trip or would you fill it later along the way?

  Start of the trip

  Later along the way


(18 years of age or younger)
If you were going to spend the weekend at friends house, (Saturday morning through Sunday evening) would you pack for the trip on Friday evening before you went to sleep, or would you pack on Saturday morning?

  Evening

  Morning


Will you be performing the tasks of this program primarily by yourself, or will you have a reliable partner?


  Self

  Partner


If you could ask the highest intellegent power in the universe one question, what would that question be?


   

 

               

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