Homework Questionnaire

Name

Describe the place(s) that you feel the most safe and comfortable (real or imagined), where nothing could bother you:

Describe unpleasant places or fears that you have:

Describe 3 specific instances when you experienced an accomplishment you have been most proud of (lots of details please!):

Expand 5 specific positive benefits to be gained from our work together & how they will change your life. Reframe to focus on positive things I WANT, add or subtract from my original benefit list on the questionnaire:

Accomplishing my objectives will change my life in these ways:

My beliefs about this objective:

Behaviors I need to change to see the results I want:

How I will know when I am successful:

Who will support you or sabotage your efforts to accomplish your objective and what might that look like?

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Henderson, NV 89074