Self Assessment Tool Form

Your Name:*

Email Address:*

How did you hear about us?*

Is this an individual assessment or business?*

What needs to BE DIFFERENT right now? Please state in less than 10 words*

Have you made clear decisions to what needs to BE DIFFERENT yet?*

YesNoNot Yet

Have you engaged in any other help to BE DIFFERENT yet?*

YesNoNot Yet

Do you have clear goals to BE DIFFERENT?*

YesNoNot Sure

Have you completed any research or analysis to support what needs to BE DIFFERENT? *

YesNoNot Sure

Please describe in 20 words or less your biggest achievement so far personally or for your business:*

Now, please describe in 20 words or less what brings you the most satisfaction personally or for your business:*

Using no more than 10 words please state what annoys, irritates or worries you the most currently about you personally or your business:*

If you had to choose only 5 key words to describe YOU, which would you choose?*

Now please choose only 5 key words to describe how ‘others’ would describe YOU.*

Using 20 words or less; please state if you could change just ONE thing, what would it be?*

What things do you feel you need to develop to improve YOU? (Please list all things; if you wish please state the level where you feel you’re at now).*

Using 20 words or less; please describe what you fear most:*

Please use just one word to summarise your greatest moment EVER!:*

I have clear objectives:*

My objectives are realistic:*

My objectives are achievable in the time set:*

Things are often out of my control:*

There hasn't been much luck lately:*

Other's don't take me seriously:*

I often sabotage my own success:*

I am extremely confident:*

I take proactive steps to get what I want:*

I often lack motivation to acheive what I want:*

I am passionate about lmy goals:*

I am an impatient person:*

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Self Assessment Tool

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