Name:

DATE WITH DESTINY® CONFIDENTIAL QUESTIONNAIRE

Welcome to your DATE WITH DESTINY and congratulations on making the decision to take your life to the next
level. You are about to embark on an extraordinary journey—one in which you will be personally guided by Anthony
Robbins to tap into the finest resources available for not only achieving your goals, but also experiencing the level of
fulfillment you truly desire and deserve.

The following questionnaire is designed to help you start thinking about your DATE WITH DESTINY and
clarify what you want to get out of it. Because we are committed to you getting what you want, it will also be used by
Tony as well as your assigned Trainers as a resource to personally support and coach you. Remember, this questionnaire
is designed to support you so there are no 'right' or 'wrong' answers. Most importantly, enjoy the process…your DATE
WITH DESTINY begins now!

We encourage you to type or neatly print your responses, using additional paper if necessary.
Fax original to: 858-713-1234

First Name: Last Name:

Address:
City: State: Zip Code: Country:
Phone (H): Phone (W):
Fax: Email:
Birth Date: Current Age: M: F:

Please list the name(s) any friends or family attending DATE WITH DESTINY with you:
Name: Relationship to you:

Marital Status:
 single  in a committed relationship  married  separated
 divorced  widowed
Spouse’s name & age: Please attach a recent
# Years in relationship: photo of yourself here.
Name(s) & Age(s) of your Children:

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SECTION I: WHY ARE YOU ATTENDING DATE WITH DESTINY?

(please use back or additional paper if you run out of space for your answers)

1. What motivated you, or what is your compelling reason, for attending DATE WITH DESTINY?

2. Describe the one thing you most want to learn, change, or reinforce:

3. How will you know if you have achieved your outcome from this program?

4. What are some of your goals for the next 12 months?

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To begin is the most important part of any quest and by far, the most courageous.
— Plato —

SECTION II: WHAT HAS YOUR LIFE BEEN ABOUT SO FAR?

5. What has been your primary focus in life? Where have you put the most time and energy?

6. Please describe four (4) events that have shaped your life, and what you learned from them:
Event #1:

What I learned from this event:

Event #2:

What I learned from this event:

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Event #3:

What I learned from this event:

Event #4:

What I learned from this event:

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Experience is not what happens to a man. It is what a man does with what happens to him.
— ALDOUS HUXLEY —

SECTION III: WHAT ARE THE BELIEFS THAT HAVE SHAPED YOUR LIFE?

7. What are some of your most important beliefs about life? (examples: life is good; life is a struggle; life
has no meaning; life is what you make it)

8. What do you believe is within your control? What are you responsible for? What is out of your control?

9. What do you believe about relationships (with a significant other, family, friends, associates)?

10. Who do you believe you are? How would you identify yourself? If you had to describe yourself to
someone else, what would you say?

11. What do you have certainty about in your life?

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12. What are you uncertain about?

13. What is most important in your life?

14. What is great in your life today? What are you excited about? What are you proud of?

15. What is missing in your life? What will it take for you to get or experience what you want?

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It is not the length of life, but depth of life.

— RALPH WALDO EMERSON —
SECTION IV: WHAT EMOTIONS DO YOU VALUE OR AVOID?

16. Please make a list of all the typical emotional states you experience at least once each week. Include
both resourceful and unresourceful emotions.

Resourceful Emotions Unresourceful Emotions

17. For at least two (2) emotions on each list (resourceful/unresourceful), describe a typical situation where
that emotion arises and what triggers the emotion. Then, if you have a particular way you either make a
good emotion better or get rid of a negative emotion, write down how you do that. Use additional paper
if necessary.
EXAMPLE
Resourceful Emotion #1:
Resourceful Emotion: Love
Situation: Situation: When I see my child
Trigger: Her smile
Enhancer: I tickle her & we
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Trigger:

Enhancer:

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Resourceful Emotion #2:
Situation:

Trigger:

Enhancer:

Unresourceful Emotion #1:

EXAMPLE
Situation: Unresourceful Emotion:
Overwhelm
Situation: When my boss asks
Trigger: for a project I haven’t finished
yet
Trigger: Hearing his voice
Eliminator: Elminator: I go outside and take
10 deep breaths.

Unresourceful Emotion #2:

Situation:

Trigger:

Eliminator:

There can be no transforming of darkness into light and of apathy into movement without emotion.
— CARL JUNG —

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SECTION V: WHAT EMOTIONS, QUESTIONS, AND SITUATIONS DRIVE YOUR LIFE?

18. In what areas of your life do you experience the most stress? What creates that stress (be specific)?

19. How do you get out of stress? What “coping mechanisms” do you use to feel better? And how well does
each of them work?

20. What emotions and behaviors do you experience on a regular basis that you would like to change/eliminate?

21. What are some of the things you do to make yourself feel great? What makes you feel really, really
good?

22. If you could have your life exactly the way you want it, how would it be?

23. What are you most grateful for in life?

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SECTION VI: PLEASE TELL US A LITTLE ABOUT YOURSELF:

Your age:  12-17  18-21  22-29  30-39

 40-49  50-59  60-64  65 or older

Your occupation:
Employed by:

Highest Level of Education Completed:

 Less than High School  High School  Jr. College/Trade School  Some College
 Bachelor’s Degree  Postgraduate Study  Postgraduate Degree

Approximate Annual Family Income (US dollars please):

 0-$24,999  $25,000-$49,999  $50,000-$74,999  $75,000-$99,999
 $100,000-$124,999  $125,000-$149,999  $150,000-$174,999  $175,000-$199,999
 $200,000-$249,000  $250,000-$499,000  $500,000-$749,000  $750,000-$999,999
 $1-$1.5 million  $1.6-$2.0 million  $2.1-$2.5 million  Above $2.5 million

Country of Your Principal Residence:

 United States  Canada  United Kingdom  Australia
 Germany  France  Italy  Spain
 Netherlands  Belgium  Singapore  Taiwan
 Mexico  Puerto Rico  Caribbean Islands  Latin America
 Other Europe  Other Asia  South America  Other: _____________

Other Anthony Robbins Products You Have Completed/Utilized:

Program Month/Year Completed/Utilized
Personal Power II: The Driving Force®
Anthony Robbins Get the Edge®
Anthony Robbins PowerTalk! ®
The Time of Your Life®
The Body You Deserve®
Living Health®
Lessons in Mastery®
Live With Passion! ®
Meetings with the Masters®
Personal Training System®
Unleash the Power Within®
Anthony Robbins Inner Balance® Products
RPM Computer Software /Planner
Other (please list):
Other Anthony Robbins Seminars You Have Attended:
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Program Month/Year Attended
Life Mastery
Wealth Mastery®
Date With Destiny®
Life Revolution/Unleash the Power Within
Living Health®
Leadership Academy/Mastery Leadership
Life & Enterprise Management
The Competitive Edge/Strategic Influence
Financial Mastery/Financial Power®
Anthony Robbins & Associates® Events:
Unlimited Power®
Power to Influence®
Breakthrough!
Breakthrough to Synergy
Breakthrough to Vital Life
Fortune Practice Management ® (please list):

What caused you to commit your time, energy, and resources to attend this DATE WITH DESTINY training?
(Please place in sequential order all those that apply, #1 being most important to your decision)
 A live presentation by Tony  Reading Unlimited Power  Reading Awaken the Giant Within
 A conversation with a friend, relative, or associate
 A letter/invitation you received from the Anthony Robbins Companies
 Listening to audiotapes (please list):
 A conversation you had with your Personal Account Representative
 A brochure you received from the Anthony Robbins Companies or an ARC representative
 Other (please describe specifically):

CONGRATULATIONS!
YOU HAVE COMPLETED YOUR QUESTIONNAIRE AND
ARE ON YOUR WAY TO YOUR DATE WITH DESTINY

The future has several names. For the weak, it is impossible. For the fainthearted, it is unknown.
For the thoughtful and valiant, it is ideal.
— VICTOR HUGO —

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