Student Information Sheet

It is suggested that you read through the form before you begin filling it out. Once it is submitted, you will not be able to retrieve it to change your answers.

Course Date:

Course City:

First Name

Last Name

Address 1

Address 2

City

State

Zip Code

Home Phone:

Cell Phone:

Business Phone

Fax

Who Enrolled/Referred You:

The following questionnaire is to help you achieve the most results from your weekend. This information will allow the instructors to assist you in reaching your goals. By clarifying your goals in your own mind, you will be better prepared to ensure a more successful weekend. We look forward to assisting you in making the weekend a valuable and rewarding experience.

FAMILY INFORMATION

Your Date of Birth

Date of

Death

Name

Age

Occupation

Personality Traits

You

Mother

Father

Oldest Sibling

Other Siblings

Spouse or Partner

Oldest Child

Other Children

EARLY RECOLLECTIONS

Enter two early recollections. An early recollection is a memory of a SPECIFIC INCIDENT that occurred when you were a child.

- Example of an early recollection:

         Age 4-5

          One day my parents brought home a new baby.

          I felt lonely and left out.

Notice that the above recollection describes a specific incident. It is not a generalized report.

- The following is NOT an early recollection:

When I was a kid I always used to ride my tricycle and fight with my brother.

It doesn't matter if the experiences you recall are positive or negative. Nor does it matter how far back you can remember, as long as they are your earliest memories. Write two recollections in the spaces below. Give your approximate age and describe how you felt.

Early Recollection 1 - Age

Early Recollection #1

ER #1 - How Did You FEEL?

Early Recollection 2 - Age

Early Recollection #2

ER #2 - How Did you FEEL?

Additional Information We Should Know

Others You Know Who Have Taken RYL

Your Employer

Your Responsibilities

How are you Valuable to Your Company?

Marital Status

Describe Your Relationship

Number of Children

Describe Your Relationship

Served in the Military

Describe your Military Experience

Have You Ever Had Counseling?

Results of Counseling

What would have made results more positive?

Have you taken other personal growth courses?

Describe Other Courses

Describe Any Major Illnesses or Injuries

Are you Currently Taking Any Medications?

List Medications

GOALS

What do you want to be different as a result of completing the Redirect Your Life Course? Be very specific about the results you want to produce in these areas.

WORK GOALS

LOVE GOALS

FRIENDSHIP GOALS

Any Final Comments/Information