Christian Therapy Services
Monday, March 18, 2019

Personal Experience Survey

  
Name:____________________________________________________
Age:______Sex:_____Marital Status:____________Date:______________
Rate each of the following statements based on your own experiences. Rate them on the following basis:
            1 = never, 2 = seldom, 3 = sometimes, 4 = often.
 
1 2 3 4       1.    In the past, I've had "mixed emotions" about things I planned to do.
1 2 3 4       2.    There have been times when the closer I got to something I wanted to do, the more afraid                            or anxious I got.
1 2 3 4       3.    I have had thoughts I wouldn't want to tell others about.
1 2 3 4       4.    I have felt confused by my own behavior.
1 2 3 4       5.    People I love have told me I gave them "mixed messages".
1 2 3 4       6.    I have felt like one part of me wanted to do one thing while another part wanted to do                                something else.
1 2 3 4       7.    I have felt like I both loved and hated the same person.
1 2 3 4       8.    I've said to myself, "I hate myself when I do that".
1 2 3 4       9.    I've been able to relate to Paul the Apostle's words, "I do the very thing I don't want to                                 do".
1 2 3 4       10.   I have had conflicts within myself.
1 2 3 4       11.   I find that I talk to myself inside my head.
1 2 3 4       12.   I have said something like, "I tell myself I need to    (start or stop something)     but I just                            don't do it".
1 2 3 4       13.   In a particular situation or relationship I've felt like I knew what to do but then I didn't                            do it.
1 2 3 4        14.   I have done things in the past that I didn't think I would do.
1 2 3 4        15.   I have said, "On the one hand I ..., but on the other hand I ..."
1 2 3 4        16.   I have done things I wouldn't want to tell others about.
1 2 3 4        17.   I criticize myself.
1 2 3 4        18.   It seems like there are different parts, sides or aspects of myself.
1 2 3 4        19.   I have felt out of control of myself in the past.
1 2 3 4        20.  I have said, "I know what I need to do but I just don't do it."
1 2 3 4        21.   I have denied myself things that I wanted.
1 2 3 4        22.   I have really desired something then been upset with myself when I went ahead and got                              it.
1 2 3 4        23. I pushed myself beyond what I thought what was good for me in the past.
1 2 3 4        24.   There have been times when my own thoughts have surprised me.
 
c 1996 Stan Eastin