Discovery! Discovery 1 Profiles

Program Location:	Gender

First Name:*	Program month you will be attending:

Last Name:*	Home Phone:*

Address:*	Work Phone:*

City:*	Cell Phone:*

State:*	Email:*

Zip:*	Marital Status:*	Spouse/Significant Other's Name

Age:*	Birthday:*

Educational Background:*

Name of School:*

Emergency Contact Name & Phone Number:*

Who are you related to in this training?*	Are you living with anyone? (Name & Relationship)*

Children (Name, Age, Birth Year):*

Employer:*	Occupation:*

Referred By:*	Referrer's Phone:*


Please give detailed and specific answers to each of the following questions.
1. Describe your quality of life.*

2. Explain the level of satisfaction that you get out of life.*

3. What is your purpose in life?*

4. What do you want to get out of the program?*

5. What has been your greatest achievement in life?*

6. What has been your greatest frustration in life?*

7. How would you rate your level of self-satisfaction?*

8. Describe your level of anger with yourself.*

9. Describe your level of anger with others.*

10. What has hurt you most in life?*

11. Explain what from your past has prevented you from enjoying life today. *

12. How would someone who knows you well describe your good traits?*

13. How would someone who knows you well describe your bad traits?*

14. What would you like to give more of to the people you care about? *

15. Describe your spiritual orientation.*

16. Describe your overall health, including limitations and medications. *

A successful submission will take you to the Payment page.