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Embrace New Life, LLCLove, Marriage & Life Counseling & Coaching

25 NOBLE COURTSUITE 121

HEATH, TEXAS 75032

Adult Intake

Embrace New Life, LLC ADULT INTAKE1

INTRODUCTION

But you are a chosen people, a royal priesthood, a holy nation, God’s special possession, that you may declare the praises of Him who called you out of darkness into His wonderful light. - 1 Peter 2:9

This is a comprehensive intake form used by the Licensed ProfessionalCounselors (LPCs) and the Professional Life Coaches (PLCs) at EmbraceNew Life, LLC to assess your strengths and needs. Before we can beginwork on your goals we need to see where you are and what you have tobuild on.

This intake form is used for both individual and couples work. In beginningour work together we ask you to adopt five key mind-sets. These will allowyou to build a life you love.

Be Curious. Curiosity makes everything new. It invites exploration and makes everything feel like play. Most of all, curiosity is going to help you look at your life in a more objective manner.

Try. When you have a bias to action, rather than sitting on the bench justthinking about what you are going to do, get in the game and commit to building your way forward to the life you want.

Reframe Problems. Thinking about something differently is how people getunstuck. It also makes sure that we are working on the right problem. Keyreframes help you step back, examine your biases, and open up new solutionspace.

Know It’s a Process. Understand that life gets messy. For every step forward,it can sometimes seem you are moving two steps back. An important part ofthe process is letting go - of your first idea and of a good-but-not-greatsolution. It’s one day at a time, and one step at a time.

Ask for Help. You are not alone. It takes a team. Commit to radical collaboration with your LPC or PLC.

Embrace New Life, LLC ADULT INTAKE 2

WHERE YOU ARE

Shade in the gauges on this dashboard from zero to full, then describe what is going on in the spaces below.

Work

Play

Love

Health

FULL0

0

0

0

FULL

FULL

FULL

DASHBOARD

Work: Play:

Love: Health:


Where You’ve Been

MARK ALL THE PLACES YOU HAVE LIVED:

YOURGIVENNAME

YOURDATE OFBIRTH

YOURPLACEOF BIRTH

YOURMOTHER’SNAME/AGE

YOURFATHER’SNAME/AGE

YOURSIBLING(s)NAME/AGE

What is your fondest memory of your MOM? What is your fondest memory of your DAD?


CHILDHOOD MEMORIES

Check the image below that you associate with your family of origin:

QUESTION #1 :You are in the 5th grade.A classmate hands outbirthday party invites but you are not givenone. When you go home, do you tell mom?

Yes

No

QUESTION #2 :If you tell your mother,how does she respond?

With Anger

She hurts for you

She tells you to ignore it

She hugs you &takes you for ice cream

5 Adjectives to describe MOM (when growing up):

5 Adjectives to describe DAD (when growing up):

My ROLE in the family:

The Caretaker

The Hero

The Scapegoat

The Lost Child

The Mascot

Favorite School Subjects:

Least Favorite School Subjects:


Childhood Ladder

1

2

3

4

5

Worst Memory

Best Memory

Your Age

Your Age

Your Age

Your Age

Your Age

Below is a Ladder that has 5 steps. Starting at the lowest (1), briefly write your worst childhood memory along with theage you were when it happened. At the top (5) briefly write your best childhood memory and the age you were when it happened. Use the other 3 steps to place other significant memories from best to worst.

My Present Life

Where I live ... What I do for a living ...

The main people in my life:Name/Age/Relationship


Present Life MATRIX

Plot the following relationships on the chart with their first names according to where they fall on the Trust and Feelings axes.

HIGH Trust

LOW Trust

DIS

LIK

E

LO

VE

YourselfYour SpouseYour ChildrenYour Parents

Your BossYour Pastor

Your Adult Siblings

Your Bestfriend

xxx

CIRCLE the names of those you know to be Christians

BOX the names of those you know struggle with drugs or alcohol

CHECK MARK the names of those you know have legal issues


Love & Marriage

The following questions apply to your past and current romanticrelationships. Please be as thorough as you can.


Love History

FIRSTLOVE,YOUR AGE

FIRSTPET,YOUR AGE

FIRSTMARRIAGE,YOUR AGE

FIRSTDIVORCENAME/AGE

SECONDMARRIAGENAME/AGE

SECONDDIVORCENAME/AGE

Timeline of Marriage(s): Plot year midpoint between first marriage and today. Then plot all marriages, divorces & your children’s births on the following timeline:

MidPoint YearYear of First Marriage This Year

LoTrust

HighTrust

Myself

LoTrust

HighTrust

Opposite Sex

LoTrust

HighTrust

My Current Spouse

LoTrust

HighTrust

Other People in general

Trust Gauges: Indicate with a ‘tick’ the level of trust in matters of love you have for the following people:


What is your Style?CIRCLE the primary type of style you identify with when it comes to your romantic relationships:

FEARFUL-AVOIDANT

When I am by myself, I am okay.But when I am in relationship, I worry that my partnermight stop loving me or become interested in someone else, When there is conflict, I want to fix it immediately.

When I am by myself, I am okay. When I am with people, I often wish I were alone.When there is conflict, I want to get away.

When I am by myself, I am not okay. I want to be with eople.When I am with people, I wish I were alone.I can’t find a happy middle.

I enjoy being in relationships and find them easy.I don’t create a lot of relationship drama.I am generally happy - alone or with people.

OUTgoing

RESERVED

SE

RIO

US

PL

AY

FU

L

PLOT yourself on this grid. In most settings, are you outgoing, reserved, serious or playful?


Love Language & Fears

When it comes to your partner/spouse, what makes YOU feel LOVED is :

Getting KUDOs & appreciation

Getting their HELP

Spending TIME together

TOUCH & Intimacy

Small GIFTs

Circle the item above that is most meaning to you.

When it comes to my partner/spouse, what makes THEM feel LOVED is :

Getting KUDOs & appreciation

Getting their HELP

Spending TIME together

TOUCH & Intimacy

Small GIFTs

I’m not sure!

What makes me AFRAIDor ANGRY in my relationship is whenI feel:

Disrespected

Not Wanted

Defective

I have no Power

Betrayed

Not Seen

Taken Advantage Of

Not Important

How I REACT:

I just leave

I yell, then leave

I insult, try to Provoke

I ignore

I ‘huff’ & ‘puff’ & give Silent Treatment

I ‘huff’ & ‘puff” & slam things

I try to talk it out

I pretend everything is OK.

I begin to think ‘I deserve better’

I go to a bad place & start Hating my spouse

My Wishfor my

Relationship:


ViewPoints &Goals

The following questions apply to your belief system and whatyou want to accomplish in our work together. Please be as thorough as you can.


Your ViewPoints

This LIFE is :

A Classroom

A War Zone

An Adventure

A Mystery

A Spiritual Journey

Spirituality is :

For losers

Too mysterious

Offensive

Foundational

Not Relevant

PreferredRELIGIONif any

Date ofCONVERSIONif any

What do you want to be remembered for? What do you want your LEGACY to be?

Your Feelings about GOD Your Feelings about the Trinity


ANXIETY Symptoms DEPRESSIVE Symptoms

Difficulty Concentrating

Difficulty falling or staying asleep

Feel Hopeless or Worthless

Change in Appetite

Lost interest in everyday things

Find it difficult to getting motivated

Feel nervous or tense alot

Have a looming sense of dread

Breathing rapidly often or holding breath

Sweat alot

Tremble alot

Feel weak or exhausted alot

Your GOAL(s)

In our work together, state your desired goal or outcome:

The amount of time I amsetting aside daily toachieve this goal:

My Readiness:

I struggle with change

I need structure

I need motivation

I’ve been ready

I have fears/concerns

My Commitment:

I need help to commit

Lo High

Have you worked with another counselor or coach on this goal or issue? If so, who?

Are you currently seeing a physician for any chronic issue? If so, what medication if any are you taking?

How did you hear about Embrace New Life, LLC?

Any current symptoms? Please check all that apply:


Do No Harm

Rule #1 in Counseling & Coaching

Embrace New Life, LLC offers faith-based counseling and coaching. There are times in our client’slife that things can feel overwhelming. Seeking help is courageous. We offer a great place to cometo heal mental health issues and to sort out emotions, feelings and goals.

There are many differences between counselors and coaches. The main difference is that counselorscan diagnose, create treatment plans, and coordinate care with your physician. Life coaches are notinterested in diagnosing clients or looking in great depth at how the past contributes to today’s functioning or dysfunctions. They are present and future focused. Both counselors and coaches areout-of-network to insurance. Counselors often focus on crisis and mental health issues. Coaches focus on goals, meaning and purpose. Coaches have more liberty to explore spirituality as counselors are beholden to psychology and state rules.

Both fields adhere to HIPAA Confidentiality laws and ethics. The counselors at Embrace New Life, LLCare licensed by the state and our coaches are certified by the American Association of ChristianCounselors. Both require advanced education, coursework and CEUs.

There are three things to remember in your work with Embrace’s counselors and coaches:

1. God is Wild About You! He is keenly aware of your strengths and weaknesses. He isn’t overwhelmedby who you truly are. He created the Universe and decided it needed you. He is always creating and inyour counseling or coaching with us, we know that His creative process becomes very personal. We respect that. We are here to assist and not hinder that process. Psalm 86:15

2. He Will Come to Your Assistance! At Embrace you will discover, if you don’t already know, that Heis indeed a Good Shepherd. He will help you along the healing process and goal achievement. Clingto Him like no other time in your life. You will not be disappointed. John 10:11

3. Meet Him. Come to counseling and coaching ready to work. He only comes by your invitation.He will not coerce or force any process. He stands ready to help. Isaiah 41:10

OUR COMMITTMENT TO YOU: We will prepare therapeutic and coaching interventions and tasks designed to facilitate healing & goal achievement. We commit to adhereing to the LPC & AACC standards of care. We commit to praying and fasting on your behalf.

Are you ready to get started?

Make anAppointment

Today!

embrace new life, llcembracenewlife.com/wp-content/uploads/2018/05/adult-intake-1.pdf · 1 embrace...

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