Core Cause Questionnaire
Give yourself permission to answer these questions truthfully.
Name *
Your answer
Email *
Your answer
Today's Date
MM
/
DD
/
YYYY
1. What is your core issue. Describe your issue?
Your answer
2. What are your negative feelings associated with the issue? Rate your feelings on a scale of 0-10. (10=strongest)
Your answer
3. What are your negative self talk or thoughts about the issue? Rate your negative self talk/thoughts on a scale of 0-10. (10=strongest)
Your answer
4. What does your culture say about this issue?
Your answer
5. Where do you feel it in your body? (Location, Color, Texture)
Your answer
6. How old were you when this issue started? Describe your earliest memory of feeling this issue.
Your answer
7. What limiting decisions or beliefs did you make related to this earlier experience in question 6?
Your answer
8. Who do you blame or hold responsible for this issue?
Your answer
9. Who in your family or earlier life modeled similar attitudes, feelings & beliefs?
Your answer
10. What benefits are you receiving by holding onto this issue?
Your answer
11. Describe what your life would be like without this issue.
Your answer
12. Looking at your old limiting decisions and beliefs what new decisions and beliefs would you like to install in yourself instead?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms