(Where appropriate ask "Did you intend that?)

Name: _________________________

Date: _________________________

01. Have you been too hard on yourself? _______

02. Have you been mean to yourself? _______

03. Have you made yourself suffer? _______

04. Do you think that it is better to suffer? _______

05. Have you harmed yourself? _______

06. Have you made yourself feel hopeless? _______

07. Have you ever let yourself down? _______

08. Have you exposed yourself to ridicule? _______

09. Have you made your life hell? _______

10. Have you felt that you should stay upset about something? _______

11. Do you feel that you are undeserving? _______

12. Have you restrained yourself? _______

13. Have you made yourself feel guilty? _______

14. Have you worried yourself? _______

15. Have you made yourself worry about things? _______

16. Have you not permitted yourself to enjoy something? _______

17. Have you tried not to want something too much? _______

18. Have you tried not to let yourself have things you wanted? _______

19. Have you tried not to want things? _______

20. Have you limited your goals? _______

21. Is there anything that you have not allowed yourself to have? _______

22. Have you held yourself back from doing something that you wanted to do? _______

23. Is there anything that you have prevented yourself from being? _______

24. Do you feel that you are stopping yourself in any way? _______

25. Have you cautioned yourself? _______

26. Have you put yourself last? _______

27. Have you made anyone else wrong for taking care of themself? _______

28. Have you made anyone else wrong for having things? _______

29. Have you inhibited yourself? _______

30. Have you invalidated yourself? _______

31. Do you ever make less of yourself to others? _______

32. Do you ever make less of yourself to yourself? _______

33. Do you feel that you are unimportant? _______

34. Have you put others or the group before your own interests? _______

35. Have you agreed with someone who was critical of you? _______

36. Have you felt that you were nothing? _______

37. Have you made yourself overly important? _______

38. Have you been arrogant? _______

39. Have you been selfish? _______

40. Have you been lazy? _______

41. Have you neglected others' best interests? _______

42. Have you ever hated yourself? _______

43. Have you ever despised yourself? _______

44. Have you ever been greedy? _______

45. Have you ever tried to grab everything for yourself? _______

46. Have you exaggerated your own importance? _______

47. Have you felt that you had too many possessions? _______

48. Have you felt that you had too much money? _______

49. Have you felt that you took too much of something for yourself? _______

50. Have you been told or taught that you shouldn't watch out for your own interests? _______

51. Have you been told or taught that you shouldn't watch out for others' interests? _______

52. Do you feel that you are holding yourself back? _______

53. Have you ever really wanted to be like someone else? _______

54. Have you idolized anyone? _______

55. Have you tried to model your life after someone else? _______

56. Have you felt that someone else was far more important than you? _______

57. Have you felt that you stressed your own importance too much? _______

58. Have you punished yourself for doing wrong? _______

59. Have you tried to be humble? _______

60. Have you neglected your health? _______

61. Have you neglected your own happiness? _______

62. Have you tried to abstain from pleasure? _______

63. Have you tried not to enjoy yourself too much? _______

64. Have you tried to dampen your own enthusiasm about something? _______

65. Have you damaged your body? _______

66. Have you inflicted pain on yourself? _______

67. Have you tried to hypnotize yourself? _______

68. Have you implanted yourself? _______

69. Have you tried to destroy your mind? _______

70. Have you tried to destroy your memory? _______

71. Have you tried to wipe out your personality? _______

72. Have you tried to force a different beingness on yourself? _______

73. Have you tried to change your ways? _______

74. Have you tried to change your personality? _______

75. Are there things that you don't like about yourself? _______

76. Is there some way in which you have made yourself miserable? _______

77. Do you have any doubts about yourself? _______

78. Do you lack confidence in yourself? _______

79. Have you tried to extinguish yourself? _______

80. Have you felt that the world or others would be better off without you? _______

81. Have you decided to leave so that you wouldn't cause any more harm? _______

82. Have you become addicted to drugs or alcohol? _______

83. Have you made nothing of yourself? _______

84. Have you blamed yourself for another's faults? _______

85. Have you tried to take responsibility for things you didn't cause? _______

86. Have you taken the credit for others' actions? _______

87. Have you failed to stand up for your own rights? _______

88. Have you worked yourself too hard? _______

89. Have you let yourself be lazy? _______

90. Have you let others get away with taking advantage of you? _______

91. Have you agreed to things you didn't want? _______

92. Have you agreed to something that was to your own detriment? _______

93. Have you agreed that you were no good? _______

94. Have you agreed that you were harmful or evil? _______

95. Have you invalidated your own opinions? _______

96. Have you invalidated your own knowingness? _______

97. Have you invalidated your own beingness? _______

98. Have you invalidated the success of your actions? _______

99. Have you invalidated your ability to be able to do things? _______

100. Have you permitted someone else to dominate you? _______

101. Have you forced yourself to do something against your will? _______

102. Have you forced yourself to do something against your own better judgement? _______

103. Have you ever made yourself feel bitter? _______

104. Have you ever made yourself regret something that you did? _______

105. Have you ever made yourself confess to things you didn't do? _______

106. Have you felt that you must be really evil? _______

107. Have you postulated something bad would happen to you? _______

108. Have you ever mocked up a bad future for yourself? _______

109. Have you allowed somebody else to adversely affect your opinions of yourself? _______

110. Have you agreed to try to change your ways? _______

111. Have you agreed to something harmful? _______

112. Have you agreed that you should limit yourself? _______

113. Have you agreed that you should have a bank? _______

114. Have you agreed that you shouldn't be mobile? _______

115. Have you agreed that you shouldn't know too much? _______

116. Have you agreed that you shouldn't remember? _______

117. Have you agreed that you shouldn't form habits? _______

118. Have you agreed that you should have a stimulus-response mind? _______

119. Have you agreed that you should learn by experience? _______

120. Have you agreed that you should be punished for your misdeeds? _______

121. Have you agreed that you shouldn't create something? _______

122. Have you agreed that you should create something? _______

123. Have you agreed that you shouldn't change your mind? _______

124. Have you agreed that you shouldn't change your agreements? _______

125. How do you feel about yourself? _______

126. How would you like to be? _______

127. Tell me some things that you would like to do. _______

128. Tell me some things that you would like to have. _______

129. Is there something that you would like to postulate for your future? _______

130. Is there any reason that you shouldn't be free? _______

131. How do your ideas about yourself compare to what they were? _______