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Name
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First Name
Last Name
Email
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example@example.com
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Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1. I recognize when my emotions begin influencing the decisions I make.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
2. I can identify situations, people, or circumstances that consistently trigger strong reactions in me.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
3.I notice patterns in my thoughts, emotions, and behavior instead of simply moving through life on autopilot.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
4. I pause long enough to understand what I am feeling before I react.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
5. I can receive criticism or disagreement without immediately becoming defensive.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
6. I can explain what is underneath a strong emotional reaction instead of only focusing on what happened.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
7. I recognize when I am repeating a behavior that has created problems for me in the past.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
8. I notice when procrastination, avoidance, or self-sabotage is keeping me from moving forward.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
9. I can identify the consequences that usually follow my repeated reactions or habits.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
10. I can acknowledge my role in recurring problems without making excuses or blaming everyone else.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
11. I am willing to question beliefs, assumptions, or stories about myself that may be holding me back.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
12. I take time to reflect on my behavior after difficult situations and consider what I could have done differently.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
13. I intentionally create space to think before responding when something matters to me.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
14. I am willing to change behaviors that no longer serve the person I am becoming.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
15. I believe I can interrupt an old pattern by becoming aware of it and choosing a different response.
1 Almost Never
2 Rarely
3 Sometimes
4 Often
5 Almost Always
What is one pattern or cycle I recognize more clearly after completing this assessment?
What situations tend to bring out the version of me I am trying to change?
What emotion is hardest for me to sit with without immediately reacting?
What story or belief might be influencing the way I respond to certain situations?
What is one reaction I want to replace with a more intentional response?
What is one small action I can take this week to interrupt an old cycle?
Your Self-Awareness Score (Out of 75)
Your Awareness Level
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