After each answer ask the question: "What were the consequences of that?"


Name: ______________________________


Date: ______________________________


01. Have you ever felt helpless? ________

02. Have you ever felt there was nothing you could do about something? ________

03. Have things seemed too overwhelming to handle? ________

04. Has it seemed that there was so much that needed to be done that there was no
point in doing anything? ________

05. Do you procrastinate? ________

06. Have you ever had to stand by and watch another suffer? ________

07. Do you know anybody who was weak and helpless? ________

08. Do you know anybody who was at total effect? ________

09. Have you ever felt that you were a failure? ________

10. Has your life ever seemed hopeless? ________

11. Have you ever contemplated suicide? ________

12. Have you ever felt that death or suicide was the only solution? ________

13. Have you ever felt that you just didn't know what was the right thing to do? ________

14. Do you wish things were different? ________

15. Are you afraid to make any changes? ________

16. Have you ever worried about others making changes? ________

17. Have you ever felt there was just no way to turn? ________

18. Have you ever felt totally exhausted? ________

19. Do things seem tiring? Have they ever? ________

20. Have you ever yearned for the past? ________

21. Have you ever felt homesick? ________

22. Are there some things that you have regretted? ________

23. Is there anything that others do that you wouldn't dream of doing? ________

24. Tell me some bad things that you haven't done. ________

25. Was there a time when restraining yourself from action was correct? ________

26. Do others cause needless upset and suffering? ________

27. Have you ever felt that there was so much suffering and misery in the world that
you shouldn't contribute more to it? ________

28. Have you had to watch another committing overts? ________

29. Have you cautioned others? ________

30. Have you ever put off doing something that you felt you really shouldn't have put off? ________

31. Is there anything that bothers you so much that you feel you should be doing
something about it? ________

32. Are there things that you worry about? ________

33. Do you ever think that it is better to suffer? ________

34. Has it ever been to your advantage to have waited rather than act immediately? ________

35. Has anyone overwhelmed you? ________

36. Do you know of anybody who has overwhelmed somebody else? ________

37. Do you feel that you may have overwhelmed somebody else? ________

38. Do you ever feel that you are waiting to have something happen? ________

39. Do you ever feel that time is passing you by? ________

40. Do you feel too old to do what you want to do? ________

41. Did you ever feel too young to do what you wanted to do? ________

42. Is there something that happened after which you felt you could never be
the same again? ________

43. Tell me some things that you protest about. ________

44. Is there something that makes you feel sad? ________

45. Is there any type of situation that makes you feel nervous or apprehensive? ________

46. Do you ever feel fearful about things? ________

47. Does the thought of something terrify you? ________

48. Are there some things that you used to feel strongly about but now no
longer care about? ________

49. Do you feel that somebody uses you? ________

50. Have you ever felt exploited? ________

51. Has anyone taken unfair advantage over you? ________

52. Is there someone you know whose overts are outrageously bad? ________

53. Are you hoping that somebody's overts will catch up with him or her? ________

54. Do you know of anybody that you think deserves to get their own back? ________

55. Have you had to do something covertly? ________

56. Do you prefer to operate behind the scenes rather than overtly? ________

57. Are you wanted anywhere? ________

58. Do you ever feel that somebody is after you? ________

59. Have any of these questions reminded you of something that you have done? ________

60. Have any of these questions reminded you of something that you have withheld? ________

61. Have you ever told part of a withhold but not the rest? ________

62. Have you ever thought of one overt or withhold and then told the auditor
something else? ________

63. Have you ever felt that it wasn't safe to tell something in a session? ________

64. Is there something that is too embarrassing to talk about? ________

65. Is there anything that you feel would be too humiliating to discuss? ________

66. Is there anything that would make you feel less if you told it? ________

67. Are there any overts that you are proud of? ________

68. Is there something that you would like to tell me about? ________

69. Tell me your ideas about your case and difficulties. ________

70. Tell me your ideas about rightnesses about yourself and your pluspoints. ________