Personal Program Questionnaire

Personal Program

Personal Program Questionnaire
  • Full name as it stands at this point in your life please. It is your energy, and it all counts.
  • DD slash MM slash YYYY
    Important to be accurate - this is your signature of entry into this life.
  • Accepted file types: jpg, jpeg, png, pdf, tiff, Max. file size: 10 MB.
    Please take a photo now, or include as recent a photo as you can.
  • Remember. everything you write here is confidential and is not shared with anyone except Jason.
  • Be direct, honest and open.
  • As emotive as you can, not analytical. Don't be the observer!
  • Objective goals or a state of mind - whatever matters most to you.
  • Any time, place or memory. No limits!
  • Don't hold back. This is about you. Don't think about anyone else at all or how they would feel about it - just You.
  • Don't think too hard. Let your emotional connection, or a burst of memory, guide you. Sometimes what we think and what we feel can be very different.
  • Again, an actual thing, event or feeling. What matters most is that it is something possible to change. If it cannot be changed, then your response to it can.
  • How you see you, not how others see you.
  • Select multiple choices by holding the CTRL key down (or 'control' key on a mac) and click on all the ones that apply.
  • This does not have to be the same email address as your Quiet Place account.
  • This field is for validation purposes and should be left unchanged.

  Thank you