| First Name: |
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| Age Range: |
20-30 |
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31-40 |
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41-50 |
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51-60 |
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61-70 |
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71-80 |
| Occupation: |
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| State you live in: |
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| Marital Status: |
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| Children: |
How many: |
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| Ages: |
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| Q1: Your definition of healthy self-esteem: |
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| Q2: What are three features you like about your face?: |
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| 2a: |
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| 2b: |
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| 2c: |
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| Q3: What are three things you love about your body?: |
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| 3a: |
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| 3b: |
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| 3c: |
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| Q4: What are the three qualities you like most about yourself?: |
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| 4a: |
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| 4b: |
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| 4c: |
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| Q5: What would your best friend say are your greatest strengths?: |
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| Q6: What qualities do you admire about your parents?: |
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| Q7: What qualities would you like to emulate from your parents?: |
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| Q8: What would you like to change about your parents?: |
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| Q9: What is one positive message you received from your parents that has helped you through challenges in your life?: |
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| Q10: What makes you glad you are a woman?: |
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| Q11: If you were a man, what would you do differently?: |
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| Q12: What are some of the negative messages you received as a child?: |
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| Q13: Which of those messages, if any, do you still believe?: |
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| Q14: What are some positive messages you received growing up?: |
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| Q15: Did you have a nickname as a child or teenager?: |
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| 15a: If yes, how did it affect you?: |
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| Q16: What teacher, coach, parent, relative, mentor or friend had the most positive impact on you?: |
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| 16a: Describe the impact: |
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| Q17: What are the obstacles or beliefs standing in the way of your dreams?: |
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| Q18: What is the one thing you would like to change about yourself?: |
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| Q19: What are some qualities or lessons you will pass on to your children?: |
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| Q20: What are your deepest fears?: |
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| Q21: What struggle would you like to overcome?: |
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| Q22: If you received an award for your most outstanding accomplishments, what would they be?: |
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| Q23: What makes you the unique and remarkable woman you are today?: |
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| Q24: What are three things you are extremely proud of?: |
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| 24a: |
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| 24b: |
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| 24c: |
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| Q25: What is the last book you read that made you feel empowered?: |
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| Q26: Complete these sentences, please: |
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| 26a: If only I could ..........., then I'd be happy: |
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| 26b: The one thing I can't seem to overcome is ............: |
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| 26c: I never feel as if I am ............: |
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| 26d: When I dream big, I imagine ............: |
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| 26e: My relationships are ..........: |
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| 26f: The way I feel about myself most of the time is ...........: |
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| 26g: I'm totally ................ with my job because it is .............: |
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| 26h: My husband/significant other makes me feel .............: |
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| 26i: My children complain that I'm too ..............: |
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| 26j: I love my ...........: |
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| 26k: I hate my ........... |
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| 26l: The best thing about my day is ...........: |
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| 26m: My relationship with God is ...........: |
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| 26n: If I knew I could succeed, I would ........... |
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| 26o: This survey is ..........: |
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| Thank you so much for your time and candor. It is appreciated and invaluable ---- just like YOU ! |
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