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.

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.
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.

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



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.

Personal Assessment

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.


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


Vision and Goals

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.


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.

* Required