Mentorship & Counseling Intake Assessment Name * First Name Last Name Date of Birth * MM DD YYYY Age Gender Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### What are your primary reasons for seeking mentorship/counseling? * Personal growth Relationship challenges Emotional healing Career/professional development Financial guidance Spiritual growth Other Explain Any other reason Describe your current life situation. (Work, family, relationships, faith, major transitions, etc.) * What are your top three personal or professional goals right now? Goal #1 Goal #2 Goal #3 What challenges or obstacles are preventing you from achieving these goals? Please Explain challenges/obstacles Emotional Well-being scale * Crisis Mode (Overwhelmed, hopeless, or emotionally distressed) Severely Struggling (Frequent distress, little to no coping strategies) Emotionally Drained (Feeling stuck, anxious, or discouraged) Struggling, but Managing (Persistent challenges but some ability to function) Emotionally Unsteady (Fluctuating emotions, managing but feeling unstable) Cautiously Hopeful (Some emotional stability with occasional struggles) Balanced, with Challenges (Generally doing well but facing occasional stress) Emotionally Strong (Feeling secure, positive, and managing stress well) Thriving (Consistently positive, emotionally resilient, and at peace) Emotionally Flourishing (Excellent well-being, inner peace, and emotional stability) Emotional Struggles Have you experienced any of the following emotional struggles in the past six months? Anxiety Depression Stress Trauma Grief Low self-esteem Angel issues Feeling stuck/unmotivated Other: Have you previously worked with a mentor, coach, or counselor? No Yes What are your main emotional triggers or stressors? How would you describe your current relationships? * (spouse, family, friends, coworkers, etc.) Do you feel supported by those around you? * Yes No Somewhat Are there any specific relationship challenges you want to address? How do you typically handle challenges or setbacks? * Avoid them Face them head-on Seek support Feel overwhelmed Other What are some of your greatest strengths? What areas of personal development do you want to focus on? Confidence building Emotional intelligence Time management Leadership skills Overcoming limiting beliefs Decision-making skills Other What is your current employment or financial situation? Employed Self-employed Unemployed Student Retired Do you have financial goals or concerns you want to work on? Budgeting Debt management Saving & investing Career advancement Entrepreneurship Other Do you feel satisfied with your current career or financial situation? Yes No Somewhat Do you have any spiritual or faith-based beliefs that are important to you? Yes No Are you interested in incorporating biblical principles into your mentorship/counseling sessions? Yes No Open to it Positive changes scale * Not Ready at All (No desire to change, resistant to growth) Highly Resistant (Aware of the need for change but unwilling to take action) Doubtful but Considering (Uncertain about change, hesitant to commit) Open but Hesitant (Recognizes need for change but struggles with follow-through) Somewhat Willing (Interested in change but inconsistent in effort) Moderately Committed (Starting to take steps but needs more motivation) Actively Engaged (Making intentional efforts toward positive change) Determined to Grow (Consistently working toward transformation) Fully Committed (Highly motivated and disciplined in making changes) All In, No Turning Back (Completely dedicated to personal growth and transformation) What are your expectations from this mentorship/counseling relationship? Is there anything else you’d like me to know before we begin? I understand that mentorship/counseling is a process that requires openness, honesty, and commitment. I agree to participate with a willingness to grow and take responsibility for my personal development. Please initials if you agree I acknowledge that all information shared during sessions will be kept confidential, except in cases where disclosure is required by law. I understand that my mentor/counselor is a mandatory reporter and must report any disclosure of the following: • Intent to harm oneself or others • Abuse or neglect of a child, elder, or vulnerable adult • Any situation where legal intervention is required to prevent harm. Please initials if you agree By typing my name and phone number below, this is my submission and I affirm that I understand these confidentiality limits and consent to engage in this mentorship/counseling relationship. Phone (###) ### #### Thank you for completing the Kornerstone Intake Assessment!We appreciate your time and openness. A team member will review your submission and follow up with you soon. If you have any questions in the meantime, feel free to reach out.We look forward to supporting you on your journey!