What is your name?

First Name

Last Name

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Thank you, ___. May I have your email to send your results?

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Do you feel like you've done "the work" on yourself but are still looping?

Select one.

Yes

No

Sometimes

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Do you feel like two parts of you want opposite things?

Eg part of you wants to be successful, part of you is afraid? Part of you wants to be healthy but part just wants to eat junkfood?

Yes

No

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Do you act ‘adult’ in some areas but ‘young’ in emotional ones?

Select one.

Yes

No

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Do you feel disconnected from your body during stress?

eg. numb, foggy, can’t feel toes

Select one.

Yes

No

Not Sure

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Which describes you most under pressure?

Select one.

Hyper-independent / shut down

People pleaser / over-functioning

Distracted / doomscroll / avoid decisions

Freeze mode

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Do you keep clothing or items from old identities ‘just in case’?

Select one.

Yes

No

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Never submit passwords Report abuse

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Do you feel like a child is driving your reactions sometimes?

Eg Overly emotional, seeking approval or asking permission from parents, tantrums

Select one.

Yes

No

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When sabotaging, what emotion hits first?

Select one.

Anger

Sadness

Numbness

Chaos

I don't sabotage

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Do your mind and body often want different things?

Select one.

Yes

No

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You get close to success/stability then collapse back?

Select one.

Yes

No

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Never submit passwords Report abuse

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What area of life do you most want to break looping sabotage behaviours in?

Select one.

Relationship patterns

Money Patterns

Habit/ addiction loops

Health Results

Confidence/ identity

All of the above

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Yes - You have a faultline!

if you answered mostly yes's then it is likely that you have a fault line holding you back. To find out more and book a call to help visit https://www.archetypalintegration.com/

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Maybe - you have a faultline

If you answered mostly yes's then it is likely that you have a fault line holding you back. To find out more and book a call to help visit https://www.archetypalintegration.com/

This form was created for FREE using Youform.

Create your own Youform

Maybe - you have a faultline

If you answered mostly yes's then it is likely that you have a fault line holding you back. To find out more and book a call to help visit https://www.archetypalintegration.com/

This form was created for FREE using Youform.

Create your own Youform

Thank you! 🙌

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This form was created for FREE using Youform.

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Do You Have a Faultline?

Yes - You have a faultline!

Maybe - you have a faultline

Maybe - you have a faultline

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