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Life Insights - Adult Evaluation by Others

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1. Hello Valued Life Insights' Client:

ACCEPTANCE OF THE FOLLOWING STATEMENTS REPRESENT A LEGAL COMMITMENT BY YOU SO PLEASE READ THE FOLLOWING VERY CAREFULLY!

Welcome to the Life Insights Adult Evaluation by Others Questionnaire for you to evaluate persons other than yourself. The purpose of this questionnaire is to create a baseline of your perceptions of another designated person (the "Designee") as a basis for identifying their self-imposed limitations, misperceptions and opportunities for optimizing their future. A Life Insights mentor will review your data input and schedule a time to discuss the results with you to clarify a mutual understanding and chart a path forward with the Designee.

This data will be a reference point in Phase 3 of the Life Insights process where the Designee will review the Life Insights summary of axioms and insights. Phase 3 is designed to introduce the Designee to a higher awareness that will hopefully advance the Designee's life progression to achieve the Designee's goals and ambitions by providing the Designee with a competitive advantage versus their peers.

The survey is somewhat lengthy in an an effort to create a comprehensive evaluation, but please take your time and carefully consider the answers to each question before answering. The end results of the Life Insights process are directly correlated to the accuracy and complete candor of your and the Designee's responses to this questionnaire and the Designee's self-evaluation questionnaire. Your responses will be compared to the Designee's responses to identify any significant variations in the Designee's self-perceptions and yours. The answers are completely confidential WITH THE DESIGNEE INCLUDED so this is an opportunity to take a serious look at the Designee in a systematic way because you genuinely care about the Designee and want to help the Designee reach their full life potential.

This questionnaire is not a test, and your participation in this process is completely voluntary and for your personal benefit and the benefit of the Designee. There are no foreseeable risks associated with this process other than the Designee's reactions to your candid responses. You certify that you have considered these potential consequences with the Designee in advance and you have both concluded that the potential benefits of the Life Insights process outweigh the risks of mutual candor about important issues.

However, if you feel uncomfortable answering any questions, you may ignore individual questions or you can withdraw from the questionnaire at any point without any disclosure to the Designee. If you want to cancel your participation after starting the questionnaire, please advise Life Insights at [email protected] as soon as you withdraw.

Your questionnaire responses will be strictly confidential and data from this process will be reported only to you and the Designee unless you and the Designee authorize others to see your responses in writing. If you have questions at any time about the questionnaire or the procedures, you may contact [email protected]

By checking the box below you certify that you are an adult over the age of 18 of sound mind and have never been diagnosed with any psychiatric disorder. You acknowledge that you are not under the care of a psychological or psychiatric care professional. You accept that Life Insights, LLC or its owners or employees incur no liability to you of any kind by allowing you to complete this questionnaire. You understand that Life Insights mentors are not licensed counselors or psychiatric professionals. You acknowledge that you and you alone are responsible for your actions, your responses or the consequences that might result from this process. If you choose to release data from this questionnaire to Designee or others, you accept full responsibility for the consequences and will hold Life Insights harmless. You acknowledge that you have discussed the implications of the Life Insights' process with the Designee and have disclosed anyone who you have authorized to see your data to the Designee AND DESIGNEE HAS CONCURRED WITH THE RELEASE. You certify that your intentions in this process are positive in trying to help the Designee.

DO NOT PROCEED WITH THIS QUESTIONNAIRE IF YOU ARE NOT IN COMPLETE AGREEMENT WITH THE STATEMENTS ABOVE OR ARE NOT EMOTIONALLY CAPABLE OF DEALING WITH ANY REACTIONS OR RESPONSES THAT MAY ARISE FROM OTHERS YOU DESIGNATE TO SEE YOUR RESPONSES!! THEIR REACTIONS ARE YOUR RESPONSIBILITY ONLY!!

Important Notice: The questionnaire format and its content are copyrighted, highly confidential and the proprietary property of Life Insights, LLC. They are not to be copied by anyone for any purpose.

Thank you very much for your time and interest in helping the Designee with their self-evaluation. Please start by selecting the "I Agree" button below and then clicking on the Continue button below.
 
 
 
2. Your Contact Information
* First Name : 
* Last Name : 
* Address 1 : 
   Address 2 : 
* City : 
* State : 
* Zip : 
* Phone : 
* Email Address : 
 
 
 
3. Please confirm your relationship to the person you are evaluating in this questionnaire (the "Designee")?
 
My biological child
 
My step-child
 
My spouse
 
My friend
 
My full sibling
 
My half-sibling
 
My adopted sibling
 
My step-sibling
 
My significant other
 
My mother
 
My father
 
My step-mother
 
My step-father
 
My employee
 
Other relationship. Please describe

 
 
 
4. Please enter the full name of the person you are evaluating (the "Designee").
   
 
 
 
5. Where was Designee in the birth order of their original family?
 
I do not know
 
Only Child
 
1.
 
2.
 
3.
 
4.
 
5.
 
6.
 
7.
 
8.
 
9.
 
10.
 
How many total siblings including you?
 

 
 
 
6. How would you rate Designee's birth family/socioeconomic circumstances versus other people in their society?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
7. How would you rate the Designee's childhood? Please comment briefly
 
I do not know
 
1. Terrible
 
2.
 
3. Not good
 
4.
 
5. Average
 
6.
 
7. Good
 
8.
 
9. Very good
 
10. Excellent
 
Briefly comment

 
 
 
8. How would you rate the Designee's childhood upbringing versus other people in their society?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
9. Please rate the quality of the Designee's educational opportunities as a child.
 
I do not know
 
1.
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
10. Overall, rate the Designee's father as a parent.
 
I do not know
 
0. Not applicable
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
Please comment if you want to

 
 
 
11. Please describe the Designee's current relationship with their father.
 
I do not know
 
0. Deceased
 
1. We have no relationship
 
2. We do not get along well
 
3. He does not care about me & we seldom communicate
 
4. He ignores me most of the time
 
5. He cares about me but we seldom communicate
 
6.
 
7.
 
8. He loves me. We are close and communicate often
 
9.
 
10. He loves me very much. We are very close and communicate very frequently
 
Please comment if you would like to

 
 
 
12. Overall, rate the Designee's mother as a parent.
 
I do not know
 
0. Not applicable
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
Please comment if you want to

 
 
 
13. Please describe the Designee's current relationship with their mother.
 
I do not know
 
0. Deceased
 
1. We have no relationship
 
2. We do not get along well
 
3. She does not care about me & we seldom communicate
 
4. She ignores me most of the time
 
5. She cares about me but we seldom communicate
 
6.
 
7.
 
8. She loves me. We are close and communicate often
 
9.
 
10. She loves me very much. We are very close and communicate very frequently
 
Please comment briefly
 
 
 
14. How would you rate the affection the Designee received from their parents as a child?
 
I do not know
 
0. Not applicable
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
15. Was the Designee physically abused a child?
 
I do not know
 
1. Often
 
2.
 
3.
 
4.
 
5. Infrequently
 
6.
 
7.
 
8.
 
9.
 
10. Never
 
Describe Briefly if you want to comment

 
 
 
16. Was the Designee verbally or emotionally abused or neglected as a child?
 
I do not know
 
1. Often
 
2.
 
3.
 
4.
 
5. Infrequently
 
6.
 
7.
 
8.
 
9.
 
10. Never
 
Describe briefly if you want to comment

 
 
 
17. How would you rate the Designee's intellect versus people in general in your society?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
18. How would you rate the Designee's overall personal appearance versus others in their age group?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
19. Overall and historically, how would you rate the Designee as an athlete?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
20. From an overall behavioral perspective, rate the Designee as a child versus their peer group.
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
21. How would you rate the Designee as a student? (past or present tense)
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
22. Please confirm the Designee's education level
 
I do not know
 
0. Currently in high school
 
1. Did not complete high school
 
2.
 
3. GED
 
4.
 
5. High school diploma
 
6. Some college
 
7. Associate degree or Technical certification
 
8. Bachelors degree
 
9. Masters Degree
 
10. Doctorate or more
 
 
 
23. Please rate the Designee's career achievement versus their age peers.
 
I do not know
 
0. Not applicable - Still a full time student
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
24. Please rate the Designee's overall career job income performance versus their age peers.
 
I do not know
 
0. Not applicable - Still a full time student
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
25. Please rate the Designee's current income performance versus their age peers.
 
I do not know
 
0. Not applicable - Still a full time student
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
26. How would you rate the Designee's current family/socio-economic circumstances versus other people in their society?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
27. How would the Designee rate their boss?
 
I do not know
 
0. Not applicable - Not employed or Self-Employed
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
28. How would you rate the Designee's career versus their aspirations at this point?
 
I do not know
 
0. Not Applicable - Young Adult
 
1. Much worse than I had hoped
 
2.
 
3.
 
4.
 
5. About what I expected
 
6.
 
7.
 
8.
 
9.
 
10. Much better than I ever expected
 
 
 
29. How would you rate the Designee as a financial provider now?
 
I do not know
 
0. Not applicable - Young adult only
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
30. How would you rate the Designee's future career prospects?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Okay
 
6.
 
7.
 
8. Good
 
9.
 
10. Great
 
 
 
31. How would you rate the Designee's current lifestyle versus their current age?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
32. How do you rate the Designee's as an achiever versus their age peer group and their potential?
 
1. Extreme underachiever
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Extreme overachiever
 
 
 
33. How would you rate the Designee as a boss?
 
I do not know
 
0. Not Applicable - I have never been a boss
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
34. How would you rate the Designee as an employee?
 
I do not know
 
0. Not applicable - Never had a job
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
35. Is the future more of a problem or an opportunity for the Designee?
 
I do not know
 
1. A big problem
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. A big opportunity
 
 
 
36. Generally, how happy is the Designee?
 
1. Very unhappy
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very happy
 
 
 
37. Overall, how does the Designee feel about their future?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
38. How much of the Designee's life potential have they achieved given their current age?
 
1. Very little
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. All of it so far
 
 
 
39. Overall, how would you rate the Designee's life experience to date?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
40. How would you rate the Designee's general outlook?
 
I do not know
 
1. Negative
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very Positive
 
 
 
41. How does the Designee feel about America's future?
 
1. Things are bad now and are likely to get worse in the future
 
2. Things are bad now and are likely to stay bad in the future
 
3. Things are bad now but are likely to get better in the future
 
4. Things are okay now but are likely to get worse in the future
 
5. Things are okay now and likely to stay okay in the future
 
6. Things are okay now but are likely to get better in the future
 
7. Things are good now but likely to get worse in the future
 
8. Things are good now and likely to remain good in the future
 
9. Things are good now and likely to get better in the future
 
 
 
42. How competitive is the Designee?
 
1. Designee prefers not to compete
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very competitive
 
 
 
43. How would you rate the Designee's breadth of knowledge versus their age group?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
44. How would you rate the Designee's sense of style versus other people in their peer group?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
45. How tactful is the Designee?
 
1. Not tactful at all
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very tactful
 
 
 
46. How persuasive is the Designee?
 
1. Not at all
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very persuasive
 
 
 
47. Generally, how would you rate the Designee's charisma?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Great
 
 
 
48. How reliable is the Designee's intuition?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
49. How would you rate the Designee's sense of humor versus other people in general?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
50. How would you rate the Designee as a conversationalist?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
51. How would you rate the Designee's overall social skills versus other people?
 
1. Poor (Very shy)
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent (Very Gregarious)
 
 
 
52. How well is the Designee generally liked by other people?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
53. How would you rate the Designee's self confidence versus your age peer group?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
54. How would you rate the Designee as a hard worker?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
55. How would you rate the Designee as a learner?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
56. How would you rate the Designee's imagination?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
57. How would you rate the Designee as a listener?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
58. How would you rate the Designee as a writer?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
59. How would you rate the Designee as a reader?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
60. How would you rate the Designee's overall personality versus other people?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
61. How would you rate the Designee as a leader?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
62. How would you rate the Designee's level of curiosity/inquisitiveness?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
63. How do you rate the Designee as a follower versus a leader?
 
1. Follower
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Leader
 
 
 
64. Is the Designee generally reactive or proactive?
 
1. Reactive
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very Proactive
 
 
 
65. Overall, how do you rate the Designee's analytical/reasoning ability?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
66. How do you rate the Designee's artistic ability?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
67. How do you rate the Designee's musical abilities?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
68. How do you rate the Designee's mathematics ability?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
69. How do you rate the Designee's mechanical/engineering/scientific understanding ability?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
70. How would you rate the Designee's business analytical abilities?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
71. How would you rate the Designee's ability to change, adapt and grow?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
72. How would you rate the Designee's ability to effectively prioritize things?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
73. How would you rate the Designee's ability to focus on tasks assigned?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
74. How would you rate the Designee's ability to innovate?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
75. How would you rate the Designee's public speaking ability?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
76. How would you rate the Designee's ability to intuitively sense other people's perspectives?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
77. How would you rate the Designee's ability to express their thoughts and feeling verbally?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
78. How would you rate the Designee's ability to productively multi-task?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
79. Overall, how would you rate the Designee's ability to communicate?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
80. How would you rate the Designee's ability to express their thoughts and feelings in writing?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
81. How would you rate the Designee's ability to maintain their composure in stressful situations?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
82. How would you rate the Designee's ability to maintain their composure in stressful situations?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
83. How would you rate the Designee's ability to overcome adversity?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
84. How would you rate the Designee's ability to get things done in a timely fashion?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
85. How would you rate the Designee's internet and computer literacy versus their age group?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
86. How much international travel has the Designee experienced versus their age group?
 
1. None
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. A lot of international travel
 
 
 
87. How would you rate the Designee's knowledge of history versus other people?
 
I do not know
 
1. Very little knowledge
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very knowledgable
 
 
 
88. How do you rate the Designee's knowledge of politics and government versus other people?
 
I do not know
 
1. Very little knowledge
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very knowledgeable
 
 
 
89. How much do you follow global events?
 
1. Not at all
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. A lot
 
 
 
90. How would you rate the Designee's common sense?
 
1. Very poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
91. How would you rate the Designee's ability to see "The Big Picture" of situations?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
92. How well would you rate the Designee's ability to see "The Big Picture" of life?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
93. How easy is it for the Designee to admit when they have been wrong about something & apologize if appropriate?
 
1. Very difficult
 
2.
 
3.
 
4.
 
5. Not easy
 
6.
 
7.
 
8.
 
9.
 
10. Very easy
 
 
 
94. How would you rate the Designee's emotional health and stability versus other people in general?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
95. How does the Designee react to constructive criticism?
 
1. With hostility
 
2.
 
3. Very defensively
 
4.
 
5. Defensively
 
6.
 
7. I ignore it
 
8.
 
9. With gratitude even if I disagree
 
10. With gratitude and careful consideration
 
 
 
96. How well does the Designee control their temper?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
97. How does the Designee act when they are very angry with someone?
 
1. Physically hostile
 
2.
 
3. Verbally hostile
 
4.
 
5. Internalize it and build resentments
 
6.
 
7. Vigorously tries to convince them that they are right
 
8. Walks away to cool off
 
9.
 
10. Maintains composure and offers solutions to resolve the conflict
 
Other: Please Describe Briefly
 
 
 
 
98. How often does the Designee get very angry or hostile toward someone?
 
1. Almost every day
 
2.
 
3.
 
4.
 
5. Often
 
6.
 
7.
 
8.
 
9. Almost never
 
10. Never
 
 
 
99. How motivated and goal oriented is the Designee versus their peer group?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
100. Overall, how open minded is the Designee?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
101. Given a choice, would Designee rather be right or happy and successful?
 
1. Right
 
2. Happy and successful
 
 
 
102. How would you rate the Designee's self-esteem?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
103. How would your rate the Designee's decisiveness?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
104. How well does the Designee take responsibility for their own happiness?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
105. How well does the Designee take responsibility for their own life?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
106. Is the Designee generally on time?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
107. Overall, how would you rate the Designee's reliability?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
108. How well does the Designee function when they are alone in their life?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
109. How would you rate the Designee's housekeeping habits?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
110. How would you rate the Designee's emotional maturity level versus their age peer group?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
111. How would you rate the Designee's patience overall?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
112. How do you rate the Designee on stubborn versus flexible?
 
1. Very stubborn
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very flexible
 
 
 
113. How well does the Designee manage stress?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
114. How would you rate the Designee's level of self-discipline?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
115. How do you rate the Designee's ability to make and keep quality friendships?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
116. How does the Designee think and make decisions?
 
1. Very emotional
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very rational
 
 
 
117. How would you rate the Designee's level of self-motivation?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
118. Overall, are is the Designee more dependent or independent?
 
1. Dependent
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Independent
 
 
 
119. Overall, how organized is the Designee?
 
1. Very disorganized
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very organized
 
 
 
120. How set in their ways is the Designee?
 
1. Very set in my ways
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Changing all the time
 
 
 
121. Overall, is the Designee more lazy or energetic?
 
1. Very lazy
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very energetic
 
 
 
122. How motivated is the Designee to excel and achieve versus their peer age group?
 
1. Not motivated
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very motivated
 
 
 
123. Generally, is the Designee more inclined to make excuses or get results?
 
1. Make excuses
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Get Results
 
 
 
124. How important are the Designee's choices to their success in life?
 
1. Not important
 
2.
 
3.
 
4.
 
5. Important
 
6.
 
7.
 
8.
 
9.
 
10. Very important
 
 
 
125. How important is the Designee's ability to compete to their success in life?
 
1. Not important
 
2.
 
3.
 
4.
 
5. Important
 
6.
 
7.
 
8.
 
9.
 
10. Very important
 
 
 
126. How would you rate the Designee's personal life judgment overall?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
127. How would you rate the Designee's professional judgment versus their age peer group?
 
I do not know
 
0. Not applicable - Still a full time student
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
128. Overall, how would you rate the Designee's ability to judge people accurately?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
129. How would you rate the Designee's financial judgment overall?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
130. How would you rate the Designee's overall personal judgment with friends in their life?
 
I do not know
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
131. How would you rate the Designee's overall personal judgment with their spouse(s) or significant others in their life to date?
 
0. Not applicable - No significant others yet
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
132. How would you rate the Designee's physical health versus their age group peers?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
133. How would you rate the Designee's weight versus the optimum for their age group?
 
1. Obese
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Ideal
 
 
 
134. What is the current marital status of Designee?
 
Single - never married
 
Separated
 
Separated but previously divorced
 
Divorced
 
Married
 
Married but previously divorced
 
 
 
135. How many adopted or step-children does Designee have?
 
I do not know
 
None
 
1
 
More than 1
 
How many total adopted or step-children doe Designee have? Please rate Designee's overall relationship with his adopted and step-child from (1) Poor to (10) Excellent

 
 
 
136. How many biological children does the Designee have?
 
I do not know
 
None
 
1
 
More than 1
 
Please list total number of children and rate Designee's relationships with their children overall (1) Poor (10) Excellent

 
 
 
137. Rate the Designee as a parent. If no children or step-children select 0.
 
I do not know
 
0. Not applicable
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
138. How would you rate the Designee's overall character versus other people in general?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
139. How would you rate the Designee's personal courage level overall?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
140. How would you rate the Designee's trustworthiness versus people in general?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
141. How would you rate the Designee's conscience?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
142. How would you rate the Designee's honesty and integrity overall?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
143. Overall, how would you rate the Designee's generosity?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
144. Overall, how would you rate the Designee's compassion and empathy for others?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
145. Overall, how well can the Designee be counted on by others?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
146. How would you rate the Designee's willingness to help others?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
147. How do you rate the Designee on selfless versus selfish?
 
1. Very self centered
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very selfless
 
 
 
148. Overall, how would you rate the Designee as a friend?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
149. Is the Designee's anger/temper an issue in your life?
 
1. A very big issue
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Not an issue at all
 
 
 
150. Is the Designee's alcohol consumption an issue in your life? If so, please describe briefly.
 
1. A very big issue now
 
2.
 
3. A very big issue in the distant past
 
4.
 
5. Somewhat of an issue now
 
6.
 
7. Somewhat of an issue in the distant past
 
8.
 
9. Never enough to be an issue
 
10. Never an issue at all
 
Please describe briefly

 
 
 
151. Is the Desinee's non-alcohol substance abuse an issue in your life? If so, please describe briefly.
 
1. A very big issue now
 
2.
 
3. A very big issue in the distant past
 
4.
 
5. Somewhat of an issue now
 
6.
 
7. Somewhat of an issue in the distant past
 
8.
 
9. Never enough to be an issue
 
10. Never an issue at all
 
Please describe briefly

 
 
 
152. Has the Designee had any DWI's or DUI's?
 
I do not know
 
1. Yes, several and recently
 
2.
 
3. Yes, several and in the distant past
 
4.
 
5. Once recently
 
6.
 
7. Once in the distant past
 
8.
 
9.
 
10. Never
 
Please describe briefly including any accidents or injuries caused by their DWI/DUI.

 
 
 
153. Is the Designee's physical abuse of anyone an issue in their life?
 
I do not know
 
1. Yes, several and recently
 
2.
 
3. Yes, several and in the distant past
 
4.
 
5. Once recently
 
6.
 
7. Once in the distant past
 
8.
 
9.
 
10. Never
 
 
 
154. Has the designee ever physically harmed someone except in self-defense? If so, please describe briefly
 
1. Yes, often and recently
 
2.
 
3. Yes, often in the distant past
 
4.
 
5. Yes, recently but infrequently
 
6.
 
7. Yes, infrequently in the distant past
 
8.
 
9. Never enough to be an issue
 
10. Never
 
Please describe briefly

 
 
 
155. Is the Designee's verbal or emotional abuse of anyone an issue in their life?
 
1. A very big issue
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Not an issue at all
 
 
 
156. Have the Designee been physically abused? If so, please describe briefly.
 
I do not know
 
1. Often in the recent past
 
2.
 
3. Infrequently in the recent past
 
4.
 
5. Often in the distant past
 
6.
 
7. Infrequently in the distant past
 
8.
 
9. Once in the distant past
 
10. Never
 
Please describe briefly

 
 
 
157. Has the Designee been verbally or emotionally abused? If so, please describe briefly.
 
1. Often in the recent past
 
2.
 
3. Infrequently in the recent past
 
4.
 
5. Often in the distant past
 
6.
 
7. Infrequently in the distant past
 
8.
 
9. Once in the distant past
 
10. Never
 
Please describe briefly

 
 
 
158. Is gambling an issue in the Designee's life?
 
1. A very big issue
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Not an issue at all
 
 
 
159. Is someone else's gambling an issue in the Designee's life? If so, please describe briefly.
 
1. A very big issue
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Not an issue at all
 
Please Describe Briefly

 
 
 
160. Has the Designee's breaking of laws been an issue in their life? If so, please describe briefly.
 
1. A very big issue now
 
2.
 
3. A very big issue in the distant past
 
4.
 
5. Minor issue recently
 
6.
 
7. Minor issue in the distant past
 
8.
 
9.
 
10. Never an issue at all
 
Please describe briefly

 
 
 
161. Has someone else's law breaking been an issue in the Designee's life?
 
I do not know
 
1. A very big issue now
 
2.
 
3. A very big issue in the distant past
 
4.
 
5. Minor issue recently
 
6.
 
7. Minor issue in the distant past
 
8.
 
9.
 
10. Never an issue at all
 
 
 
162. Is the Designee's reckless spending been an issue in their life? If so, please describe briefly.
 
I do not know
 
1. A very big issue now
 
2.
 
3. A very big issue in the distant past
 
4.
 
5. Minor issue recently
 
6.
 
7. Minor issue in the distant past
 
8.
 
9.
 
10. Never an issue at all
 
Please describe briefly including the magnitude if a current issue
 
 
 
163. Is someone else's reckless spending an issue in the Designee's life?
 
I do not know
 
1. A very big issue now
 
2.
 
3. A very big issue in the distant past
 
4.
 
5. Minor issue recently
 
6.
 
7. Minor issue in the distant past
 
8.
 
9.
 
10. Never an issue at all
 
Please describe briefly including the magnitude of the issue if current

 
 
 
164. Is the Designee's unemployment an issue in their life?
 
0. Not applicable - The Designee is fully employed
 
1. A very big issue
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Not an issue at all
 
 
 
165. Is someone else's unemployment an issue in the Designee's life?
 
1. A very big issue
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Not an issue at all
 
Describe Briefly

 
 
 
166. Has infidelity by the Designee been an issue in their life? If so, briefly describe.
 
I do not know
 
0. Not applicable - I have never engaged in infidelity
 
1. An issue recently in my life
 
2.
 
3. A recurring issue in my life
 
4.
 
5. A one time issue in my distant past
 
6.
 
7.
 
8.
 
9.
 
10. Not an issue at all
 
If so, Briefly Describe With Time Frame

 
 
 
167. Has someone else's infidelity been an issue in the Designee's life? If so, please describe briefly.
 
I do not know
 
0. Not applicable - I am not aware of infidelity by a significant other or spouse
 
1. A recent issue
 
2.
 
3. A recurring issue in my life
 
4.
 
5. A one time issue in my life
 
6.
 
7.
 
8.
 
9.
 
10. Not an issue at all
 
If So, Briefly Describe With Time Frame

 
 
 
168. Is your dishonesty or untrustworthiness an issue in the Designee's life?
 
1. A very big issue
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Not an issue at all
 
 
 
169. Is someone else's dishonesty or untrustworthiness an issue in the Designee's life?
 
1. A very big issue
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Not an issue at all
 
 
 
170. How does the Designee feel about tattoos?
 
I do not know
 
1. They love them - They have many
 
2. They like them - They have a few
 
3. Maybe in the future
 
4. They have some that they wish were gone
 
5. No way ever
 
 
 
171. Please check any issues below that apply to the Designee even if they are infrequent.

The goal is to identify issues to be addressed so it is important to be candid with the Designee.

Note: Select the answers & other if you want to add other issues or comments
 
1. Character issues
 
2. Lack of conscience/compassion for others
 
3. Self-centered
 
4. Lazy
 
5. Shyness
 
6. Unmotivated
 
7. Dishonesty
 
8. Infidelity
 
9. Bad temper
 
10. Irresponsible
 
11. Alcohol or substance abuse
 
12. Gambling
 
13. Recklessness
 
14. Self-imposed limitations
 
15. Depression
 
16. Making excuses
 
17. Poor professional life judgment
 
18. Poor personal life judgment
 
19. Smoking
 
20. Law breaking
 
21. None of the above
 
Other

 
 
 
172. Are there things in the Designee's past that are adversely affecting their life today?
 
I do not know
 
1. Many things
 
2.
 
3.
 
4.
 
5. Some things
 
6.
 
7.
 
8.
 
9.
 
10. Nothing
 
Describe briefly

 
 
 
173. Are there significant fear factors that affect the Designee's life?
 
I do not know
 
1. Many
 
2.
 
3.
 
4.
 
5. Some
 
6.
 
7.
 
8.
 
9.
 
10. None
 
Describe Briefly

 
 
 
174. How would you rate the Designee as a spouse/life partner? ANSWER "I DO NOT KNOW" IF YOU ARE NOT THE DESIGNEE'S SPOUSE OR LIFE PARTNER
 
I am not the Designee's spouse or life partner
 
0. Not applicable - They have never had a spouse or significant other
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
175. How would you rate the Designee as a lover? ANSWER "I DO NOT KNOW" IF YOU ARE NOT THE DESIGNEE'S SPOUSE OR LIFE PARTNER
 
I do not know
 
0. Not applicable - No experience
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
176. How would you rate the Designee as a friend to you if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable - I have never had a spouse or significant other
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
177. How would you rate the Designee as a social asset to you if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable - I have never had a spouse or significant other
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
178. How would you rate the Designee as a professional asset to you if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable - I have never had a spouse or significant other
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
179. How would you rate the Designee on affection and intimacy with you if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable - I have never had a spouse or significant other
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
180. How would you rate the Designee on trustworthiness with you if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable - I have never had a spouse or significant other
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
181. How would you rate the Designee on their willingness to compromise with you if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
182. How would you rate the Designee on their willingness to consistently place your relationship above other concerns if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable - I never had a spouse or significant other
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
183. How would you rate the Designee's willingness to apologize and seek reconciliation after conflict?
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
184. How would you rate the Designee's willingness to let go of resentments?
 
0. Not applicable
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
185. How would you rate the Designee's ability to express their true thoughts and feelings and communicate with you if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable - Designee has never had a spouse or significant other
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
186. How would you rate the Designee's ability to offer positive solutions to issues and work to achieve permanent solutions to issues with you. if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable - Designee has never had a spouse or significant other
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
187. How would you rate your overall common interests and shared life priorities with the Designee if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable - Designee has never had a spouse or significant other
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
188. How would you rate the Designee in making your relationship a top priority and honoring their commitments to you if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable - Designee has never had a spouse or significant other
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
189. How would you rate the Designee as a source of support for you if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable - Designee has never had a spouse or significant other
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
190. How would you rate the compatibility of you and the Designee on parenting if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable - Designee has never had a spouse or significant other
 
1. Not compatible
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Very compatible
 
 
 
191. How would you rate your compatibility with the Designee as a spouse or life partner. CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.
 
I do not know
 
0. Not applicable - Designee has never had a spouse or significant other
 
1. Poor
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Excellent
 
 
 
192. Is sex a problem in your relationship with the Designee if you are the spouse or significant other of the Designee? CHOOSE "I DO NOT KNOW" if you are not the spouse or significant other of the Designee.your spouse or significant other? If no spouse or significant other now, refer to your last previous relationship.
 
I do not know
 
0. Not applicable - Designee has never had a spouse or significant other
 
1. A big problem
 
2.
 
3.
 
4.
 
5. Average
 
6.
 
7.
 
8.
 
9.
 
10. Not at all
 
 
 
193. How important is a good relationship with a spouse or significant other to Designee's happiness?
 
I do not know
 
1. Not important at all - Designee prefers being alone
 
2.
 
3. Not important enough to deal with all the issues
 
4.
 
5. Very important - Designee does not like to be alone
 
6.
 
7. Important but Designee is too busy now with other things
 
8.
 
9. Important but not necessary
 
10. Very important to Designee but it has to be with someone very special
 
 
 
194. How would you describe Designee's romantic nature?
 
1. Romance? Are you kidding?
 
2.
 
3. Romance is a dead notion of a bygone era
 
4.
 
5. Romance is okay but it never lasts
 
6.
 
7. Romance is important to Designee but they never see it
 
8.
 
9. Romance is important to Designee and can be very enjoyable
 
10. Designee believes that romance that endures is important to a successful intimate relationship
 
 
 
195. Where is sex on Designee's list of priorities? Select more than 1 choice if applicable. If you are not the spouse or significant other of Designee, please choose "I do not know"
 
I do not know
 
1. Sex is a means to get what Designee wants
 
2. Designee does not like sex
 
3. Designee believes sex is great but desire is hard for Designee to sustain with one person
 
4. Designee believes sex is way overrated
 
5. Sex is okay but not that important to Designee
 
6. Sex is great and very important to Designee
 
7. Sex is important to Designee but a lot of other things are more important to Designee
 
8. Sex is important to designee but only in a committed intimate relationship
 
9. Designee believes good sex is an important way to express affection
 
10. Designee believes good sex is an important element in an enduring relationship
 
Other: Describe briefly or comment if you want to

 
 
 
196. Please rate Designee's personal happiness among Designee's overall life priorities.
 
1. Very low priority
 
2.
 
3.
 
4.
 
5. Important
 
6.
 
7.
 
8.
 
9.
 
10. Very high priority
 
 
 
197. Please rate Designee's spouse's or significant other's happiness among Designee's overall life priorities.
 
I do not know
 
0. Not applicable - Designee does not have a spouse or significant other
 
1. Very low priority
 
2.
 
3.
 
4.
 
5. Important
 
6.
 
7.
 
8.
 
9.
 
10. Very high priority
 
 
 
198. Please rate Designee's relationship with Designee's spouse or significant other among Designee's life priorities.
 
I do not know
 
0. Not applicable
 
1. Very low priority
 
2.
 
3.
 
4.
 
5. Important
 
6.
 
7.
 
8.
 
9.
 
10. Very high priority
 
 
 
199. Please rate Designee's children's happiness among Designee's overall life priorities at his point in their lives.
 
0. Not applicable
 
1. Very low priority
 
2.
 
3.
 
4.
 
5. Important
 
6.
 
7.
 
8.
 
9.
 
10. Very high priority
 
 
 
200. Please rate Designee's career among Designee's overall life priorities.
 
1. Very low priority
 
2.
 
3.
 
4.
 
5. Important
 
6.
 
7.
 
8.
 
9.
 
10. Very high priority
 
 
 
201. Please rate material things among the Designee's life priorities.
 
1. Very high priority
 
2.
 
3.
 
4.
 
5. Important
 
6.
 
7.
 
8.
 
9.
 
10. Very low priority
 
 
 
202. Please rate friends among the Designee's life priorities.
 
1. Very low priority
 
2.
 
3.
 
4.
 
5. Important
 
6.
 
7.
 
8.
 
9.
 
10. Very high priority
 
 
 
203. Most people have elements of more than one personality profile so please select the personality traits that apply to Designee to some degree.

Then rate the items you chose with a percentage that applies to Designee for each choice you made to reach a total of 100% for all traits.
 
A. Type “A” Personality - Leaders - Entrepreneurial, risk takers, direct, innovative, self-motivated, dislike routine, enjoy change, focused, decisive, persistent, and can be insensitive and impatient. Socially functional because it is a necessity to reach their ambitions, but can turn off other people. Rely on their intellect, leadership qualities and knowledge to succeed. Achieving success is very important.
 
B. Type “B” Personality - Socially oriented – Love excitement and to party and travel, enjoy groups, like being center of attention, supportive of friends, want to be liked by others and easily hurt if rejected, good public speakers, talkative, personable, persuasive, outgoing extroverts. Rely more on their personalities than their expertise to succeed. Tend to think more emotionally than rationally. Enjoying life is very important.
 
C. Type "C" Personality - Artistic and creative oriented - Usually fashionable or flaky dressers. Enjoy expressing their active imaginations through writing or other artistic expression. Socially interesting but can be reserved. Tend to think more emotionally than rationally. Often have difficulty with analytical thinking and mathematics. Rely on their artistic talents to succeed. Expressing themselves through their art is very important.
 
D. Type “D” Personality - Detail and analytically oriented – Precise, organized, consistent, predictable, responsible, thoughtful, slow to make decisions, emotionally sensitive, inquisitive, loyal, and patient. Think more rationally than emotionally. Rely on their expertise to succeed. Can struggle in social settings. Understanding the details is very important.
 
E. Type “E” Personality - Status quo lovers – Dislike change, prefer the predictable, enjoy repetitive tasks, security oriented, compassionate of others, happy, punctual and content. Rely on consistent conformity to succeed. Preparing for a great retirement is very important.
 
F. Type “F” Personality - Underachievers – Can be very bright, but low self-esteem and/or motivation are obstacles to their life potential. Inward focused and prefer to settle for less in life rather than to aspire for more and have to face the potential for failure. Rely on low self-expectations to avoid dealing with success. Avoiding competition and accountability is very important.
 
G. Type “G” Personality - Self destructive – Reject societal expectations, and engage in self-destructive behavior without concern for the adverse effects on their life potential. Every problem they have is someone else’s fault. Success is being a non-conformist. Doing whatever they want is very important.
 
List a percentage of each personality type that applies to you to total 100%:

 
 
 
204. Where would you rate the Designee on the political spectrum?
 
1. Very Liberal
 
2. Liberal
 
3. Independent
 
4. Moderate
 
5. Conservative
 
6. Very Conservative
 
7. Libertarian
 
8. I do not care about politics
 
 
 
205. How concerned is the Designee about political outcomes in 2012?
 
1. Not concerned at all
 
2.
 
3.
 
4.
 
5. Concerned
 
6.
 
7.
 
8.
 
9.
 
10. Extremely concerned
 
 
 
206. Comments/Suggestions:
   
 
 
 
207. Please release this completed questionnaire to the following person(s) at the listed e-mail address(es):
   
 
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