Performance Blocking Beliefs Questionnaire

Performance Blocking Beliefs Questionnaire
Name*
First Last
Performance Problem I want to solve:*
INSTRUCTIONS: Please give each belief a number from 1 (feels completely untrue) to 7 (feels completely true) for each statement.
I will never get over this problem.*
Completely untrue 1 2 3 4 5 6 7 Completely true
I am not sure I want to get over this problem.*
Completely untrue 1 2 3 4 5 6 7 Completely true
I don’t have the strength, ability or will power to get over this problem.*
Completely untrue 1 2 3 4 5 6 7 Completely true
If I talk about or try to get help for this problem, something bad will happen.*
Completely untrue 1 2 3 4 5 6 7 Completely true
This problem can only be solved by someone else.*
Completely untrue 1 2 3 4 5 6 7 Completely true
I should solve this problem, but I don’t always do what I know I need to do.*
Completely untrue 1 2 3 4 5 6 7 Completely true
If I get over this problem, the outcome will be negative or bad.*
Completely untrue 1 2 3 4 5 6 7 Completely true
I say I want to solve this problem, but I never do.*
Completely untrue 1 2 3 4 5 6 7 Completely true
I don’t deserve to get over this problem.*
Completely untrue 1 2 3 4 5 6 7 Completely true
This problem is bigger than I am.*
Completely untrue 1 2 3 4 5 6 7 Completely true
Someone in my life is upset with me because I have this problem.*
Completely untrue 1 2 3 4 5 6 7 Completely true
There are some good things about having this problem.*
Completely untrue 1 2 3 4 5 6 7 Completely true
I don’t have a problem.*
Completely untrue 1 2 3 4 5 6 7 Completely true
I have had this problem for so long, I could never completely solve it.*
Completely untrue 1 2 3 4 5 6 7 Completely true
I have to wait to solve this problem.*
Completely untrue 1 2 3 4 5 6 7 Completely true
If I solve this problem, I could lose a lot.*
Completely untrue 1 2 3 4 5 6 7 Completely true
If I solve this problem completely, it will be mainly for someone else – not for me.*
Completely untrue 1 2 3 4 5 6 7 Completely true
I should not have to deal with this problem.*
Completely untrue 1 2 3 4 5 6 7 Completely true
This problem is not my responsibility.*
Completely untrue 1 2 3 4 5 6 7 Completely true
WRITE A LIST OF SOME OF YOUR OWN BLOCKING BELIEFS THAT DETRACT YOU FROM SETTING AND REACHING YOUR PERFORMANCE GOALS.*
Name
This field is for validation purposes and should be left unchanged.

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