resolution form

RESOLUTION FORM

(Fill out and bring to the first appointment) To print out the page press CTRL + P

Please number each words from 0 to 10. 0 is not a problem in your life, 10 is a huge problem.

  • Fear
  • Defensive
  • Overwhelmed
  • Burdened
  • Shame
  • Blame self
  • Rage
  • Run down.
  • Inhibited
  • Bad body image
  • Unrecognized
  • Betrayal
  • smart enough
  • Fear of failure
  • Mistrust
  • Over emotional
  • No self discipline
  • Fear of not being liked
  • Emotionally closed down
  • Over responsible
  • Got to be perfect
  • Aggressive communication
  • Sadness
  • Apprehensive
  • Controlling
  • Worry
  • Embarrassed
  • Unlovable
  • Scape goat.
  • Disorganized.
  • Shy
  • Abandoned
  • Seeking approval
  • Not good enough
  • Seeking attention
  • Fear of success
  • Over sensitive to criticism
  • Can't express emotions
  • Fear of public speaking
  • Trapped
  • Sexually closed down
  • Angry with authority
  • Say "I should, must or have too" a lot.
  • Anger
  • Stressed
  • Controlled
  • Regret
  • Powerless
  • Disappointed
  • Pressured.
  • Self doubt.
  • Obsessive
  • Unworthy
  • Failure
  • Resentment
  • Power tripper
  • Non-committal
  • Fear of authority
  • Confused
  • Stuck
  • The Victim
  • Negative thinking
  • Got to be right
  • Not communicating
  • Guilt
  • Panic
  • Heartache
  • Grief
  • Rejected
  • Judgemental
  • Push over
  • intolerant
  • Inflexible
  • Distant
  • Erratic
  • Martyr
  • Rebellious
  • Impatient