Christian Therapy Services
Tuesday, April 24, 2018

Personal Experience Survey I

  
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