[form] REFRAME personal profile this form is for you to profile how things are on a regular basis during counselling. You will profile yourself in 7 Key areas of engaging life both in terms of awareness and freedom to act. With each you will also be asked to sense what you are feeling and how intense it is AT THIS PRESENT TIME. Your Name please: [text,r_name,30] Email: [text,r_email,30] CONTEXT or BACKGROUND If you are using this profile to reflect how you're handling a situation you're facing, a context which you're working with or which is influencing you, please take time to describe it. AFTER that keep it in mind when you profile each of the seven areas of engagement. This means that the selections will be relative to the context you're talking about. [textarea,Context or Background,3,70] =========================================================== 1. FEEDBACK Being aware of your surroundings and others and the influence they have. Being free to respond to your surroundings with your commentary, view, opinion, or action. [list,Awareness of FEEDBACK] [option,0,Your Awareness of FEEDBACK] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] [list,Freedom to work with the FEEDBACK] [option,0,Your Freedom to work with the FEEDBACK] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] WHAT emotions or feelings are you aware of as you make this assessment of FEEDBACK WHAT level of intensity do you experience it at present? [list,FEEDBACK emotion] [option,Anger,Anger] [option,Fear,Fear] [option,Aversion,Aversion] [option,Attraction,Attraction] [option,Sadness,Sadness] [option,Joy,Joy] [option,Acceptance,Acceptance] [option,Disgust,Disgust] [/list][list,Intensity FEEDBACK emotion] [option,How Intense?,How Intense?] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] FEEDBACK brief comment? [text,FEEDBACK comments,80] ========================================================= 2. PRIORITIES - Ordering things by Being aware of the ORDER in which things are best to happen. Being free to respond by initiating WHEN things happen. [list,Awareness of PRIORITIES] [option,0,Your Awareness of PRIORITIES] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] [list,Freedom to work with the PRIORITIES] [option,0,Your Freedom to work with the PRIORITIES] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] WHAT emotions or feelings are you aware of as you make this assessment of PRIORITIES WHAT level of intensity do you experience it at present? [list,PRIORITIES emotion] [option,Anger,Anger] [option,Fear,Fear] [option,Aversion,Aversion] [option,Attraction,Attraction] [option,Sadness,Sadness] [option,Joy,Joy] [option,Acceptance,Acceptance] [option,Disgust,Disgust] [/list][list,Intensity PRIORITIES emotion] [option,How Intense?,How Intense?] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] PRIORITIES brief comment? [text,PRIORITIES comments,80] ====================================================== 3. CONTROL - BLAME Being aware of who is responsible for how things are. Being free to take responsibility and work with it. [list,Awareness of CONTROL-BLAME] [option,0,Your Awareness of CONTROL-BLAME] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] [list,Freedom to work with the CONTROL-BLAME] [option,0,Your Freedom to work with the CONTROL-BLAME] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] WHAT emotions or feelings are you aware of as you make this assessment of CONTROL-BLAME WHAT level of intensity do you experience it at present? [list,CONTROL-BLAME emotion] [option,Anger,Anger] [option,Fear,Fear] [option,Aversion,Aversion] [option,Attraction,Attraction] [option,Sadness,Sadness] [option,Joy,Joy] [option,Acceptance,Acceptance] [option,Disgust,Disgust] [/list][list,Intensity CONTROL-BLAME emotion] [option,How Intense?,How Intense?] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] CONTROL-BLAME brief comment? [text,CONTROL-BLAME comments,80] ==================================================== 4. UNDERSTANDING Being aware of your self and your point of view. Being free to express your point of view and to engage that of others [list,Awareness of UNDERSTANDING] [option,0,Your Awareness of UNDERSTANDING] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] [list,Freedom to work with the UNDERSTANDING] [option,0,Your Freedom to work with the UNDERSTANDING] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] WHAT emotions or feelings are you aware of as you make this assessment of UNDERSTANDING WHAT level of intensity do you experience it at present? [list,UNDERSTANDING emotion] [option,Anger,Anger] [option,Fear,Fear] [option,Aversion,Aversion] [option,Attraction,Attraction] [option,Sadness,Sadness] [option,Joy,Joy] [option,Acceptance,Acceptance] [option,Disgust,Disgust] [/list][list,Intensity UNDERSTANDING emotion] [option,How Intense?,How Intense?] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] UNDERSTANDING brief comment? [text,UNDERSTANDING comments,80] ======================================================= 5. ALTERNATIVES Being aware of your options or alternatives to how things are. Being free to negotiate for those you want to alter and to keep those you wish to keep unchanged [list,Awareness of ALTERNATIVES] [option,0,Your Awareness of ALTERNATIVES] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] [list,Freedom to work with the ALTERNATIVES] [option,0,Your Freedom to work with the ALTERNATIVES] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] WHAT emotions or feelings are you aware of as you make this assessment of ALTERNATIVES WHAT level of intensity do you experience it at present? [list,ALTERNATIVES emotion] [option,Anger,Anger] [option,Fear,Fear] [option,Aversion,Aversion] [option,Attraction,Attraction] [option,Sadness,Sadness] [option,Joy,Joy] [option,Acceptance,Acceptance] [option,Disgust,Disgust] [/list][list,Intensity ALTERNATIVES emotion] [option,How Intense?,How Intense?] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] ALTERNATIVES brief comment? [text,ALTERNATIVES comments,80] ==================================================== 6. AGREEMENTS Being aware of the rules, cultural expectations, group expectations, promises received and given, and those whom you share them with. Being free to keep aligned with expectations by rules, culture, and to keep promises you've made. [list,Awareness of AGREEMENTS] [option,0,Your Awareness of AGREEMENTS] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] [list,Freedom to work with the AGREEMENTS] [option,0,Your Freedom to work with the AGREEMENTS] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] WHAT emotions or feelings are you aware of as you make this assessment of AGREEMENTS WHAT level of intensity do you experience it at present? [list,AGREEMENTS emotion] [option,Anger,Anger] [option,Fear,Fear] [option,Aversion,Aversion] [option,Attraction,Attraction] [option,Sadness,Sadness] [option,Joy,Joy] [option,Acceptance,Acceptance] [option,Disgust,Disgust] [/list][list,Intensity AGREEMENTS emotion] [option,How Intense?,How Intense?] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] AGREEMENT brief comment? [text,AGREEMENT comments,80] ====================================================== 7. RESPONSE Being aware of your own responses and those of others. Being free to make your active or passive response to invitations or to make your own invitations for a response [list,Awareness of RESPONSE] [option,0,Your Awareness of RESPONSE] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] [list,Freedom to work with the RESPONSE] [option,0,Your Freedom to work with the RESPONSE] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] WHAT emotions or feelings are you aware of as you make this assessment of RESPONSE WHAT level of intensity do you experience it at present? [list,RESPONSE emotion] [option,Anger,Anger] [option,Fear,Fear] [option,Aversion,Aversion] [option,Attraction,Attraction] [option,Sadness,Sadness] [option,Joy,Joy] [option,Acceptance,Acceptance] [option,Disgust,Disgust] [/list][list,Intensity RESPONSE emotion] [option,How Intense?,How Intense?] [option,Zero,Zero] [option,Low,Low] [option,Medium,Medium] [option,High,High] [/list] RESPONSE brief comment? [text,RESPONSE comments,80] ================================================================ Your general sense of BODY areas where your attention is caught or centred during this profiling [checkbox,Upper head - brow - eyes] Upper head - brow - eyes [checkbox,Lower Head - nose - ears - mouth] Lower Head - nose - ears - mouth [checkbox,Throat and upper chest and arms] Throat and upper chest and arms [checkbox,Chestarea - upper back] Chestarea - upper back [checkbox,Upper stomach area] Upper stomach area [checkbox,Lower Stomach area] Lower Stomach area [checkbox,Thighs - hips - legs - feet] Thighs - hips - legs - feet ================================================================ PLEASE CHOOSE THE LEVEL OF FUNCTIONALITY FROM THIS SCALE [list,My General assessment of the Impact is] [option,0,The level of IMPACT on me is...] [option,1 The absence of any distress,1 The absence of any distress. Feeling calm and totally relaxed] [option,2 Neutral feeling or just OK,2 Neutral feeling or just OK, not as relaxed as could be] [option,3 Increased discomfort,3 Increased discomfort, unpleasant, but in control] [option,4 Noticeable discomfort or distress,4 Noticeable discomfort or distress, perhaps agitation, but tolerable] [option,5 Discomfort is very uncomfortable,5 Discomfort is very uncomfortable, but I can stand it.] [option,6 Discomfort worsens and affects my life,6 Discomfort worsens and affects my life] [option,7 Discomfort is severe emotional pain interferes,7 Discomfort is severe and emotional pain interferes with my life.] [option,8 Discomfort increases in thoughts constantly,8 Discomfort increases and it is in my thoughts constantly] [option,9 Nearly intolerable,9 Discomfort is nearly intolerable] [option,10 discomfort extreme worst imaginable,10 Discomfort is extreme and the worst imaginable. I feel panicky and overwhelmed.] [/list] [list,Rating of LIFE] [option,1 LIFE OK, I rate my LIFE as - OK] [option,2 LIFE NOT OK, I rate my LIFE as - NOT OK] [/list] [list,Rating of FUTURE] [option,1 FUTURE is OK,I rate my FUTURE as - OK] [option,2 FUTURE is NOT OK,I rate my FUTURE as - NOT OK] [/list] ============================================================= YOUR GENERAL REFLECTIONS JOURNAL During this profiling of your awareness and freedom some things may have come up for you. Images, memories, thoughts or other ideas. Please journal them here as you feel free to or comment here to enable further understanding by the counsellor. [textarea,TODAYS JOURNAL,5,60] =============================================================== It is recommended that you request a personal copy of this profile. It will give you a concrete record of your personal progress in working on your life. [checkbox,send copy,checked] LEAVE CHECKED TO receive a copy of your work here. Uncheck it if you have printed off a hardcopy for yourself. [submit,SEND this Entry][reset,Start Over again] [/form]