Assessment Of Challenges

The Assessment of Challenges form should be completed and submitted at least 24 hours prior to your first appointment, or when requested. Answers to each of the Assessment questions is optional, but it is encouraged that you complete as many as possible.

When you complete and submit the form, copies of your answers will be emailed to us and to you, so please be sure your email address is entered correctly.

If you have any questions, please Contact Us.

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Tell us about yourself

Name

Email

Repeat to confirm

Phone Number

When is your appointment

Do these completions quickly by writing in your first thought. This will help you to develop insight about how well you manage the problems in your life.

The biggest challenge I’m facing is:

I’m quite concerned about:

One of my other problems is:

Something I do that gives me trouble is:

Something I fail to do that gets me into trouble is:

Assessment of Challenges (Continued)

The social setting of my life I find most troublesome is:

The most frequent negative feelings in my life are:

They take place when:

The person I have most trouble with is:

What I find most troublesome in this relationship is:

Assessment of Challenges (Continued)

Life would be better if:

I tend to do myself in when I:

I don’t cope very well with:

I get anxious when:

A value I fail to put into practice is:

Assessment of Challenges (Continued)

I’m afraid to:

I wish I did, or didn’t:

What others dislike about me is:

What I don’t seem to handle well is:

I don’t seem to have the skills I need in order to:

Assessment of Challenges (Continued)

A problem that keeps coming back is:

If I could change just one thing in myself it would be:

How long have you struggled with these challenges?

Any other comments or information I should know:

You may review and modify any of your answers prior to submitting by using the next/previous buttons. Once you click submit, the answers will be emailed to us and a copy emailed to you. Please let us know if you have any questions

@2008, www.DwightBain.com permission granted to reproduce this coaching tool providing this disclaimer is not removed.