The Circle of Life

Self-Inquiry Assessment Form1997 Health Action, McLean-Jahnke

TM

by Rebecca McLean & Roger Jahnke

Nutrition&

Diet Exercise&

Fitness

Stress Mastery

Self-Care

Relationships

Work &Career

FinancialHealth

Creativity&

Play

Environment

Emotions &Self-Esteem

Life Purpose&

Service

Spirituality&

Intuition5

5

5

5

10

10

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Your Readiness for Change AssessmentAfter reading through the previous paragraphs about readiness for change, please

consider the aspect of your life you want to work on and see if you are really Ready forChange, in this area, now. It is very important to know if you are in the readinessphase. This knowledge will be helpful when you are deciding on what you want to change,how long it may take, and what changes you are ready to make now. This information willalso help your facilitator to support you in the process of improvement.

On a scale of 1 to 10, mark your score in each area. Total your score on the bottom of thenext page.

1) How satisfied are you with this area of your life right now?

Very Dissatisfied = 10Somewhat Satisfied = 5Very Satisfied = 1 Your score _______

2) Do the Pros outweigh the Cons at this time in your life?

All pros = 101/2 pros and 1/2 cons = 5All cons = 1 Your score_______

3) Has your emotional, mental, physical pain or stress level reached thepoint where you are ready to change?

High stress or pain = 10Moderate or tolerable stress or pain = 5Low or no pain or stress = 1 Your score_______

4) How much does your desire for comfort motivate you?

High desire for comfort = 10Some desire for comfort = 5Not motivated by desire for comfort = 1 Your score_______

5) Would this time, or would the near or distant future (weeks, months, yearfrom now) be a better time to focus on this area of your life?

Good timing = 10Not good, but not really bad = 5Poor timing = 1 Your score_______

6) Are you on the verge of or experiencing a crisis or loss that activates yourreadiness to change?

Loss or crisis is high and now = 10Crisis is very likely in the future = 5Crisis is possible, but not for a year or more = 1Does not apply in my life = 0 Your score_______

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7) Are you prepared for the responses of significant people in your life if youmove forward to make this change? How will you respond if they aredisapproving, fearful, controlling, insecure or in any way resistant?I am prepared to move forward with this change = 10I will be slowed down by a non-supportive response = 5I will not move forward if significant people in my life

are resistant to this change = 1 Your score_______

8) How much is this change being done for you, as opposed to someone else?Is this a change you want for yourself?

Changing for myself = 10Changing is 1/2 for me and 1/2 for someone else = 5Changing for someone else, not really for me = 1 Your score_______

9) Do you have the resources and support systems in place ready to help youinitiate, overcome obstacles, follow-through and maintain thisimprovement?

Support and resources systems in place and ready = 10Partial support and resources ready, but would needmore to insure success = 5Do not have support or resources = 1 Your score_______

TOTAL from All Sections TOTAL SCORE_______

Add your totals from all the sections. If your total Score is:

0 to 40 = Not Ready for Change now (Red light) Pleaseread the following paragraphs.

41 to 50 = Possibly Ready for Change, maybe not.(Yellow light) Please read the options below beforeproceeding.

51 to 90 = Ready for Change (Green Light)

The total will give you an idea of your readiness level. If you got a low score inreadiness, this is not to discourage you from proceeding with the area that you havechosen to work on. It will give you feedback as to what you need to do to become moreready. Please read the following material to help you determine your options.

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Acknowledge & List Your Strengths & Victories

Intention / Goal:

Challenges:

Affirmation:

Action Steps:

Accountability:

Goal •Affirmations •Action Steps •Accountability•Challenges

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Mon ThursTues Wed SatFri Sun

Weekly Action & Accountability SheetYour Positive Actions Create the Life You Want

Weekly Commitments

Affirmation:

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