2022 KOSTA 개인 상담 신청서

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Waiver of Liability (상담 동의서)* This field is required.The undersigned, seeking a biblical life coaching adhered by KOSTA/USA, hereby acknowledges his or her understanding of the following conditions and further releases to the life coaching program, its mentors, and staffs, from any liability or claim arising from the undersigned’s participation in the above-mentioned the life coaching program: 1) It is understood by the participant that the life coaching program will be provided by supervised mentors, not as licensed therapists; 2) That all programs provided during KOSTA Conference is in accordance with the biblical principles adhered to its ministry and are not necessarily provided in adherence to any local or national psychological or psychiatric association; 3) That no representation has been made, either expressly or implied, that the life coaching, as conducted by the mentors, is accepted as customary psychological and/or psychiatric therapy within the definitional terms utilized by those professions. 4) Certain statements may not be protected as privileged communications under law. Do you agree with Waiver of Liability?
YESNO
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I hereby agree to the following conditions: * This field is required.1) I assure to keep confidential information from the mentoring session. (저는 세션 중 거론된 상담가의 정보 포함, 개인적인 내용은 비밀로 지키기로 약속합니다.) 2) I am committed to resolving/adjusting/rectify my problems by coming into obedience to the Word of God. (저는 세션 중 거론된 문제를 하나님의 말씀인 성경 안에서 풀어나가기로 약속합니다.) 3) If I am dissatisfied in any way with the session, I will first discuss it with the program staff directly. (세션의 결과에 불만이 있을 경우, 상담실 스태프와 먼저 상의를 먼저 할 것을 약속합니다.) 4) Mentors and mentees have a right to report the session if they notice severe life-threatening situation. (상담가와 내담자는 세션 중에 생명에 지장이 있는 응급상황이 감지될 경우 관련 기관에 신고할 수 있는 권리가 있습니다.) *** If you have any questions about these guidelines, please consult with the KOSTA staff or one of our mentors. (위의 내용에 질문이 있을시에는 상담실 스태프나 상담자님께 상의해주시면 감사하겠습니다.) I, (아래 자신의 이름 서명), affirm the accuracy of the personal information provided herein, and have read the information above and agree to the conditions set forth therein that the life coaching I receive will be based on the mentor’s understanding of the Bible as the Word of God and its practical applications.
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성별* This field is required.Gender
남(male)
여(female)
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이름* This field is required.Name
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나이* This field is required.Age
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조번호* This field is required.Group #
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전화번호* This field is required.Phone #
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e-mail address* This field is required.
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희망상담가* This field is required.Preference of Counselor
Male / 남자상담가
Female / 여자상담가
No preference / 상담실추천
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희망 상담 시간-최대 2항목 선택 가능 (오전 선택은 LGS시간과, 오후 선택은 점심시간이나 세미나 시간과 겹칠 수 있음을 알려드립니다.)Preferred Time to Meet
화요일 오전
화요일 오후
수요일 오전
수요일 오후
수요일 저녁식사 시간 (6:00-7:00 PM)
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전문 상담, 심리치료를 받으신 적이 있으신가요?* This field is required.Have been treated for a psychiatric, emotional, or mental illness?
YESNO
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코스타 상담실에서 상담을 받으신 적이 있으신가요?* This field is required.Have you ever experienced the KOSTA life coaching?
없음 (None)
1회 (Once)
2-3 회 (2-3 times)
4회 이상 (More than 4)
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원하는 상담 분야* This field is required.Desired KOSTA life coaching topics
관계 (Relationship)
신앙생활 (Faith)
진로 (Career)
재정 (Financial Difficulties)
중독 (Addiction)
내적치유 (Inner Healing)
정신 건강 (Mental Health)
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상담분야-관계 문제Relational Issues--원하는 상담분야에서 관계를 선택하셨을 경우 작성해 주십시오.
또래 친구들과의 관계
학교 선/후배와의 관계
지도교수 및 선생님과의 관계
교제하는 친구와의 관계
가족과의 관계
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상담분야-신앙생활Faith Issues--원하는 상담분야에서 신앙생활을 선택하셨을 경우 작성해 주십시오.
교회 생활 (Local church)
개인 영적 신앙 성장
캠퍼스 사역 (Campus Ministry)
소그룹 사역 (Small Group Ministry)
성경공부 인도 (Leading a Bible Study)
선교 (Mission)
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상담분야-진로Career Issues--원하는 상담분야에서 진로를 선택하셨을 경우 작성해 주십시오.
진로 선택 (Career Choices)
비전과 신앙생활
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상담분야-정신 건강Mental Health Issues--원하는 상담분야에서 정신건강을 선택하셨을 경우 작성해 주십시오
낮은 자존감 (Low Self-Esteem)
불면증 (Sleep Difficulties)
정서불안 (Anxiety)
우울증 (Depression)
자해 (Self-Injurious behaviors)
섭식문제 (Unhealthy Eating Habits)
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예전만큼 사람들과 어울리는 것이 즐겁지않다.* This field is required.I don't enjoy being around people as much as I used to.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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내 자신이 가치없게 느껴진다 (내 존재가치를 발견하기 어렵다.)* This field is required.I feel worthless (I don't find much value in myself).
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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내 삶의 소망이 없다고 느껴진다 (내 삶의 미래가 잘 보이지않는다.)* This field is required.I feel hopeless (I don't see a future in my life).
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 고립되어 있고 외롭게 느껴진다.* This field is required.I feel isolated and alone.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 슬픈 날이 그렇지 않는 날보다 더 많게 느껴진다.* This field is required.I feel sad more days than not.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 생을 마감하고 싶은 생각을 한다.* This field is required.I have thoughts of ending my life.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 수면 문제를 겪고 있다.* This field is required.I have sleep difficulties.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 평소 걱정을 멈추는 것이 어렵다.* This field is required.I feel like I can’t turn my mind off.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 극심한 압박이나 공포를 느낀다.* This field is required.I have spells of terror or panic.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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큰 이유없이 심장이 뛴다.* This field is required.My heart races for no good reason.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 자주 긴장상태에 있다.* This field is required.I feel tense.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 사람들이 나를 좋아하지 않을 것을 염려한다.* This field is required.I am concerned that other people do not like me.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 사람들의 시선을 의식한다.* This field is required.I feel self-conscious around others.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 모르는 사람들과 만나는 자리를 가급적 피한다.* This field is required.I avoid a situation where I am surrounded by people I don't know.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 최근 평소만큼 집중이 잘 되지 않는다.* This field is required.I am not able to concentrate as well as usual.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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동기부여 되는 것이 어렵다.* This field is required.It is hard to stay motivated.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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내 일을 지속하는 것이 어렵다.* This field is required.I am unable to keep up with my work.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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내가 무엇을 하든지 잘 해낼 자신이 있다.* This field is required.I am confident I can succeed in whatever I do.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 내가 원하는 것이상으로 아래와 같은 행동을 떠올리거나 생각한다. (해당 사항 모두 선택)* This field is required.I think about _____________ more than I would like to. (Check all that apply)
None
Disordered eating (섭식문제)
Internet Use (인터넷사용)
Game (게임)
Cell Phone (핸드폰사용)
Videos (동영상)
Alcohol (술)
Smoking (담배)
Drugs (마약)
Sexual life (성생활)
Shopping (충동구매)
Self-injurious behavior (자해)
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나는 아래와 같은 행동을 할때 통제가 되지 않음을 느낀다. (해당 사항 모두 선택)* This field is required.I feel out of control when I _____________. (Check all that apply)
None
Disordered eating (섭식문제)
Internet Use (인터넷사용)
Game (게임)
Cell Phone (핸드폰사용)
Videos (동영상)
Alcohol (술)
Smoking (담배)
Drugs (마약)
Sexual life (성생활)
Shopping (충동구매)
Self-injurious behavior (자해)
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나는 아래와 같은 행동을 한 후에 종종 후회하곤 한다. (해당 사항을 모두 선택)* This field is required.I often regret after _____________. (Check all that apply)
None
Disordered eating (섭식문제)
Internet Use (인터넷사용)
Game (게임)
Cell Phone (핸드폰사용)
Videos (동영상)
Alcohol (술)
Smoking (담배)
Drugs (마약)
Sexual life (성생활)
Shopping (충동구매)
Self-injurious behavior (자해)
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나는 술을 마시면 무슨 일이 있었는지 기억이 나질 않는다.* This field is required.When I drink alcohol I can't remember what happened.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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내 성질/화를 통제하는데 어려움이있다.* This field is required.I have difficulty controlling my temper.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 쉽게 화가 난다.* This field is required.I get angry easily.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 말다툼에 자주 개입된다.* This field is required.I frequently get into arguments.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 가끔 물건을 부수거나 치고 싶은 생각이 들곤한다.* This field is required.I sometimes feel like breaking or smashing things.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 내가 나를 통제하지 못해서 폭력적인 행동을 할 수도 있다는 두려움을 느끼곤한다.* This field is required.I am afraid I may lose control and act violently.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
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나는 다른 사람을 해치고 싶은 생각을 한다.* This field is required.I have thoughts of hurting others.
Not at all like me
Somewhat not like me
Neutral
Somewhat like me
Extremely like me
46
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