Destination Motivation Form

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Destination Motivation Goal Assessment

Hi, I'm Jason, your Life Transformation Coach. The opportunity to become your newest and best self awaits. In the next 30-60 minutes, you will answer a series of questions that will help you and I gain a deep understanding of what your true needs, conscious or unconscious, are. Let's get started. Click Start to begin:

40Questions

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Destination Motivation is designed to help you reach your goals. If you are interested in a more fulfilling and spiritual approach to life transformation, you will want to exit now and fill out the "8 Degrees of Transformation Assessment" instead.
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Name* This field is required.
First Name
Last Name
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Date* This field is required.
Date
Year
Month
Day
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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What days of the week are best to reach you? You may select multiple days:* This field is required.
Monday
Tuesday
Wednesday
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Friday
Saturday
Sunday
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If you selected MONDAY through FRIDAY, what is the best time to reach you? If not, leave this question blank.
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If you selected a day on the Saturday or Sunday, what is the best time to reach you? If not, leave this question blank.
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List 4 of the most pressing things about yourself that you would fix right now if you could (anything):
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Think about the last month. List up to 4 of the most emotionally charged times you had and why:
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Do you have any mental illnesses that you are aware of? Do you feel these illnesses are under control?
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Do you have any physical or medical ailments that you know of that cause you distress?
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Think about some interactions you have had with people at work or school recently (good and bad). List them out and describe how you felt about the situations and how you dealt with the situation in a sentence or two.
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Think about the last week. Any moments where you felt sadness, anger, and anxiety? What caused those emotions and how did you deal with resolving the situation?
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Have you went hungry in the past month due to the inability to afford food? If so, how often?
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Have you been unable to get healthcare in the past month due to the inability to afford medical care or medical insurance?
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Is any person treating you emotionally or physically in such away that inhibits your ability to better yourself?
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How often would you say you feel sadness related to feeling alone or lonely?
Never
Once or twice a month
Once a week
Once or twice a week
Every day
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How often would you say you show sincere and honest kindness or love to others (not including your spouse)?
Never
Once per week
Several Times per Week
Every day
Multiple times per day
Every hour
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How many times in the previous week have you practiced gratitude or felt thankfulness about something?
Never
Once per week
Several Times per Week
Every day
Multiple times per day
Every hour
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How often would you say you experience strong anger toward others?
Never
Once per week
Several Times per Week
Every day
Multiple times per day
Every hour
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How often would you say you show disrespect toward others?
Never
Once per week
Several Times per Week
Every day
Multiple times per day
Every hour
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How often do you hold grudges against people?
Often, and with quite a few people
Once in a while when someone has done me wrong, but only a small handful
Very seldom unless they have hurt me deep and it’s only one or two people
Never. I cannot hold grudges.
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List the first 4 people that come to mind whom you feel negative feelings about. In a few words, name why:
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Name 4 things that bring you absolute joy:
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Name up to 4 dreams you’ve had since you were child:
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If you could do anything in the world, list up to 4 of those things:
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What are 4 things things you want right now?
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If you could have any job in the world, what would it be?
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If you could travel or live anywhere in the world, where would it be?
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If you could leave a legacy behind after you’re gone, what would it be?
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If you could be someone else, who would you be and why?
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If you knew you only had a few years to live and unlimited money, list 8 things you would do with the time you have left.Bucket List Identification
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If you had absolutely nothing holding you back and had ultimate power to do whatever you want for the rest of your life, what additional 8 things would you accomplish?
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Are there any issues you have mentally or personally that you would want to work on? Think about your current basic needs and if they are being fulfilled (e.g. hunger, depression, abandonment, weight gain, anger issues, abuse, self-esteem, etc). What could be the solution to each of these issues?Reflect on Self
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Do you struggle with any addictions? These could be drugs, food, alcohol, pornography, cigarette smoking, deviance, etc. What potential goals could you work on in these areas? What could be their solutions?Separation of One's Self
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Do you read or watch the news or take part in anything that could affect your happiness? Would working away from some of these items help you be able to reach more goals and achieve happiness?Separation of One's Self
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Think about how much you exercise and what your diet is like. Do you feel like there are any goals you might want to consider that will help improve your health?Wellness
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What creative hobbies do you have or want to pursue and how much do you feel you could devote to those hobbies each day or week?Creativity
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Do you have any weak points in your ability to relate to others? What goals could you potentially look at regarding your conduct? (kindness, caring, love, respect, courtesy, forgiveness)Conduct
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