Breakthrough Orientation Questionnaire

Personal Development Breakthrough Questionnaire

Congratulations on your commitment to participate in the ChoiceCenter Personal Development Breakthrough Workshop.

This form is meant to assist you in your preparation for the Course, as well as provide ChoiceCenter Breakthrough trainers and staff with information to better serve you. Please review this form carefully and answer each question in its entirety. Your forms must be completed and returned before you can begin the workshop.

As with Discovery, Breakthrough is effective when you take full responsibility for your participation, value, and well-being. We find that the people who benefit most from our programs are adults who have already achieved a certain measure of accomplishment, learning, and success. This form should help answer any questions you may have and may also help clarify your vision and goals.

Like Discovery, Breakthrough is an intense, highly participatory workshop designed to deal with life issues in an honest and meaningful way. You will be requested to participate fully, as well as challenge yourself and others. In Breakthrough, there is a higher level of inter-personal activity required. This workshop is designed to be a breakthrough environment and will not always be comfortable.

The format of the Breakthrough includes a variety of breakthrough processes. Please read the descriptions in this form so that you are fully informed and responsible with respect to your participation in Breakthrough. For those willing to 'go the distance” in this workshop, there is life-altering value. It is our privilege to serve you.

First Name *

Last Name *

Birthdate (Must Be 18) *

City *

State / Province *

Zip Code *

Home Phone

Cell Phone *

Email *

Occupation *

Employer *

Referred By: *

You have finished the Welcome Section. Please select "NEXT" to go to the Training Schedule section.

Attendance of the six sections is required to attend: Thursday through Sunday and the Completion Evening/Guest Training.

BREAKTHROUGH SCHEDULE
Thursday	Registration Training Starts Ends Approximately	11:30 am 12:00 pm 12:00 am
Friday	Training Starts Ends Approximately	12:00 pm 12:00 am
Saturday	Training Starts Ends Approximately	12:00 pm 12:00 am
Sunday	Training Starts Ends Approximately	11:00 am 7:00 pm
Tuesday Following	Guests Evening Call in for 30 minutes	6:30 pm

You have finished the Training Schedule Section. Please select 'NEXT' to go to the Health Information section.

You have finished the Training Schedule Section. Please select "NEXT" to go to the Health Information section.

Please answer all of the following questions completely. Your answers will be kept confidential.

The information you provide here will enable our trainers and staff to better support your participation. If during the training, you find yourself feeling uncomfortable to an excessive degree, you should report this immediately to the trainer or to a staff member.

If you have any questions about the appropriateness of your participation at this time, please consult a trained professional. In some cases, as instructed in the next section of this form, we require that you do so in order to participate in the training.

1. Gender *

Male

Female

1b. Are You Pregnant? *

Yes

No

2. How many hours of sleep do you normally get? *

6 hours or less

6-7 hours

8-9 hours

9+ hours

3. Have you had any therapy or psychological counseling prior to a year ago? *

Yes

No

4. Are you currently in therapy? *

Yes

No

4b. Have you been in therapy or counseling within the last 12 months? *

Yes

No

5. Have you ever been hospitalized for psychiatric care or for a mental disorder? *

Yes

No

6. Have you ever been prescribed any medications commonly used to treat emotional illness? *

Yes

No

7. Have you ever had a nervous breakdown that you’ve been treated for? *

Yes

No

8. Do you have any physical limitations that are likely to be an obstacle to your participation in Breakthrough? *

Yes

No

Important: If you answered 'Yes' to any
part of question 4, and “No” to questions 5, 6, 7 and 8, read and follow the directions in Section A.

If you answered 'Yes' to questions 5, 6, 7 or 8, read and follow the directions in Section B.

You have finished the Confidential Health Information Section. Please select "NEXT" to go to the Emergency Contacts section.

Emergency Contacts: Must have two contacts with complete information

CONTACT #1

Name *

Relationship *

Phone *

Work Phone

CONTACT #2

Name *

Relationship *

Phone *

Work Phone

Verification

I hereby acknowledge and attest that I am over age 18 and have thoroughly and carefully read the information contained herein. I understand it, and have answered all of the questions fully and truthfully. I take full responsibility for my participation in Personal Effectiveness Discovery and Breakthrough.

Name *

Today's Date

Personal Assessment

Full Name *

Workshop LV#

Personal Data

Please be specific and complete in answering the following questions. Use additional paper if necessary. Your answers are designed to assist choiceCenter Breakthrough Trainers and staff in serving you and will be kept confidential.

1. Briefly describe your marital history and present marital status *

2. List the names and ages of any children that you have. *

3. List the names of the people with whom you live, and their relationship to you. *

4. Briefly describe your past and current religious views and practices. *

5. Briefly describe any past or current military service (location, branch, rank, duty) including any wars or conflicts in which you've been engaged. (Write N/A if not applicable.) *

6. Briefly describe your present career status, occupation, work or job. *

7. List your educational background including your highest degree earned. *

8. List the social, career, religious, political or community organizations to which you belong *

Health

9. What is the current status of your health? Identify any health problems and their current condition. List any drugs you are taking or have taken in the past six months (prescription and non-prescription). State symptoms or health condition treated by the specified medication. *

10. Are you pregnant? *

(If you are pregnant you may not participate in ChoiceCenter’s Breakthrough course; we invite you to participate at another time.)

Yes

No

11. Are you currently or have you ever been addicted to alcohol, marijuana, cocaine, heroin, or any other narcotic? *

Yes

No

11a. Describe your addiction

Self-Evaluation

12. Describe your physical appearance. *

13. Describe three key events (preferably from your childhood) that have most influenced who you are. Include your beliefs about yourself and others – as well as the world around you – as a result of these events.

13a. *

13b. *

13c. *

14. List the names of three people who, if asked, would give you honest, straightforward feedback about how you show up in the world. Next to their names, describe the feedback they would have for you*

14a. *

14b. *

14c. *

Vision and Goals

15. What is a vision for your life that would inspire and motivate you to give of yourself fully to see it realized. Describe that vision in detail. *

16. What commitments do you need to declare, what are the ways of being you need to access and what actions do you need to take to manifest your vision? Be specific. *

The purpose of Ground Rules is to assist a group of people in working cooperatively within a consistent framework. On the first day of the workshop the trainer will review the Ground Rules and ask you to agree to them as a condition for participating in the Breakthrough Workshop. A list of the ground rules is included below:
1. Keep other participants' words and actions completely confidential Please note: ChoiceCenter cannot guarantee confidentiality.
2. Attend the entire 4-day session and the Tuesday Guest Information Call at 6:30PM PST on the Tuesday following Breakthrough.
3. Be on time. Be seated before the music ends. (Just prior to the beginning of each session, and after each break, we play a piece of music that is about 1-1/2 minutes long.) The training starts at 12 pm on Thursday; 12 pm on Friday; 12 pm on Saturday; and 11 am on Sunday.
4. Do not side talk. Ask questions, talk and share only when acknowledged by the trainer or during designated sharing periods.
5. Do not eat, chew gum, or drink beverages inside the workshop room.
6. Do not use tobacco (cigarettes, chew, etc.), alcohol, marijuana or other similar non-prescribed mood altering drugs through the completion of Sunday of the workshop.
7. Be responsible for your own well-being. Get sufficient food and sleep and take any prescribed medications on schedule.
8. Do not sit next to someone you knew prior to the Personal Development Course.
9. Wear your name tag in a visible location during Course hours. Turn in your name tag before meal breaks and at the end of each day.
10. Turn off all cellular phones, pagers and other electronic devices before entering the Breakthrough Course room.
11. Do not take notes, photographs, or make video or audio recordings in the training room.
12. Establish no new romantic and/or sexual relationships with ChoiceCenter coaches, staff members, or any students until 30 days following your TEAM’S completion of the ChoiceCenter Leadership training.
Recommendations: 1. Sit in open body position. 2. Be sensitive to when you leave the training room to use the bathroom. 3. Respect other users and the physical plant of this facility.

Acknowledge *

I acknowledge reading the Ground Rules.

Breakthrough Orientation Questionnaire