Life Script Questionnaire

Name:
Address:
Date: Date of Birth:

1. Describe yourself briefly (adjectives):

2. Are you the child your parents wanted (explain):

3. Describe your mother briefly:

4. Describe your father briefly:

5. What adults, other than your mother and father, had a decisive influence on your life
when you were young (identify and describe):

6. What were your originally told about your birth:

7. What did your mother say when she felt good:

8. What did she say when she was upset or felt bad:

9. What was her favorite saying about life in general:

10. What did she want for you in life:

11. Did that agree with what you wanted? If yes, have you got it? If no, how did you
resolve the difference:

12. What did your father say when he felt good:

13. What did he say when he was upset or felt bad:

14. What was his favorite saying about life in general:

15. What did he want for you in life:

16. Did that agree with what you wanted? If yes, have you got it? If no, how did you
resolve the difference:

17. What other names have you been known by and/or called yourself? What special
meaning did/do these have for you? For others (identify):

18. Are you what you claim you want to be (explain):

19. Does this equate to what the world wants you do be:
20. Briefly describe how grown-ups talked to you as a child:

21. When you were punished, what was mild and what was severe:

22. What punishment was most common:

23. What thoughts, feelings, or attitudes were you not to reveal in your childhood:

24. What do you like most about yourself? What would you like others to most like in
you:

25. What do you now say and believe about life:

26. What did you say and believe about life as a teenager:

27. What did you say and believe about life when in grade school:

28. What did you like least about yourself:

29. What is there about yourself you are most eager to change:
30. How do you handle disagreement:

31. What are your requirements for a person to be your friend? Are these your
requirements or what you were told to expect:

32. What does sex mean to you:

33. How does your meaning compare to your experience:

34. In childhood, what special, unusual, and/or foreign words were taught to you to
substitute for the name of body functions, parts of the body, and/or sex:

35. Which of these have you passed along, or do you still use:

36. How do you refer to your own body parts:

37. How do you feel immediately after sex:

38. Have you had much injury, illness, surgery (explain):

39. What purpose does your life hold for you:

40. Have you ever wished to die (explain):

41. Describe the bad feeling you have most often experienced:

42. What’s your earliest recollection of having such a bad feeling:

43. What childhood stories did you like best:

44. What person in the story did you like best, and what did you like about the person:

45. Suppose your present troubles continue, what will you be doing five years from now:

46. If you change in the ways you desire, what will you be doing five years from now:

47. What does death mean to you:

48. At what age have you thought you would die and how would death occur:
49. If you were to die today, what would you write on your tombstone? What is the final
word on the epitaph which you didn’t have room for:

50. What would others write instead:

51. What do you wish your mother had done differently:

52. What do you wish your father had done differently:

53. Have you ever suffered a loss (explain):

54. What religion do you practice:

55. How does your practice add to, subtract from, or confuse your present lifestyle:

56. Is this the same religion you were taught to practice as a child:

57. Do you enjoy your practice? If not, why do you continue:

58. Suppose magical changes were possible, what or how would you change:
59. What do you want most out of life:

60. What were you denied as a child which you are presently denying yourself:

61. Who or what is your biggest obstacle in your life right now:

62. What do you expect will be done in the process of the change you now seek:

63. List the ways you might sabotage those changes you seek: