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:
