FREE SURVEY | EssentialThriveTribe

First name

Last name

Email

Phone

Birthday

Month

Day

Year

How do you feel when you think about your childhood?

Mostly Positive

Mostly Negative

Difficult to remember anything particular

I'm not sure

Which statement best describes your relationship with parents growing up?

Loving and supportive

Close and nurturing

Distant but respectful

Challenging with frequent conflicts

Strained and emotionally disconnected

Abusive or harmful

Absent OR grew up without my parents

Mixed with both positive and negative aspects

Did you experience any of the following when you were a kid?

Choose all that apply

Did you experience any of these major challenges?

Choose all that apply

I say sorry a lot, even when I don't need to

1 star = strongly disagree

5 stars = strongly agree

I avoid conflict due to fear

1 star = strongly disagree

5 stars = strongly agree

I like being independent and rarely ask for help

1 star = strongly disagree

5 stars = strongly agree

I dwell on small mistakes

1 star = strongly disagree

5 stars = strongly agree

I find it hard to build and keep healthy relationships

1 star = strongly disagree

5 stars = strongly agree

I often swing between oversharing and hiding my feelings

1 star = strongly disagree

5 stars = strongly agree

I shut down when people criticize me

1 star = strongly disagree

5 stars = strongly agree

I tend to over explain myself and my choices

1 star = strongly disagree

5 stars = strongly agree

Do you know how to heal your inner child so that past experiences stop negatively affecting you?

Yes

No

Did you have needs that went unfulfilled in childhood?

Yes

No

Did you have needs that went unresolved in childhood?

Yes

No

Did you feel emotionally dysregulated as a child?

Yes

No

Do you feel emotionally dysregulated as an adult?

Yes

No

How do you think trauma affects your life?

Choose all that apply

How could your life improve by working through past traumas

Choose all that apply

What do you want to improve your relationships?

Improve emotional expression and connection

Build trust and rapport

Juggle personal and relationship priorities with balance

Get better at solving conflicts

Speak up and set healthy boundaries

Build and maintain healthy relationships

Reconnect with loved ones

Choose all that apply

How busy are you on an average day?

I rarely get time to myself

I stay busy but carve out time to relax

I maintain a moderate level of busy-ness

My schedule is quite open and adaptable

Do you have any of the following sleep problems?

Trouble falling asleep

Keep getting up at night

Wake up feeling tired

None of the above

Choose all that apply

What's your core motivation to dealing with past trauma?

Choose all that apply

What was your childhood like?