Reason for Seeking Assessment/Treatment: ______

SYMPTOM CHECKLIST

Name:______Date:______

Reason for seeking assessment/treatment: ______

______

Please check any of the concerns or symptoms listed below that you are currently experiencing:

___marriage/relationship problems___loss of interest in previous activities

___difficulties with family___recurrent flashbacks

___difficulties with friends___episodes of lost time, unexplainable actions

___school problems___trouble with memory or concentration

___step-family problems___confusion

___divorce issues___much fantasy or daydreaming

___serious physical illness (self or family)___hyperactivity/attention problems

___health concerns (self or family)___headaches/stomach aches

___fatigue/low energy___sexual problems

___death of family member or friend___sexual identity concerns

___anxiety/worry/nervousness___identity concerns

___panic attacks___feelings of unreality

___reluctant to leave home or familiar neighborhood___obsessive thoughts/excessive fears

___perfectionism___unusual thoughts or perceptions

___guilt/shame feelings___excessive energy

___trouble sleeping___impulsive decisions or actions

___depressed mood/sadness___difficulty trusting others

___suicidal thoughts___low self-esteem

___self-injury___avoidance of conflict

___eating habits___withdrawn, isolating

___spending habits___shy/uneasy around others

___concerns about behavior/habits/compulsions___fear of failure

___concern about alcohol/drug use___fear of disapproval

___concern about lying or dishonesty with others___need to please others and be liked

___anger/irritability___difficulty saying “no” to others or asserting self

___mood swings___difficulty making independent decisions

___loss of temper/outbursts___feelings of futility/loss of hope

___aggressive/violent behaviors___loss of joy in living

___physical abuse of self (current or past)___physical abuse of others

___verbal/emotional abuse (current or past)___other ______

1. Please rate the overall level of stress that you feel is currently pressing on you, including life changes, work, family, and finance. (Circle appropriate number)

12345

minimal moderate extreme

comment:

2. Please describe how your concerns or symptoms are interfering with:

a. your quality of life and inner well-being:

b. your relationships:

c. your work/school:

d. your health

3. In thinking about your network of friends, family, etc., how would you rate the amount of helpful social support currently available to you.

12345

none some, but adequate

not adequate

4. As a result of therapy or assessment, what specific results or changes do you wish to see happen:

5. If you have had any previous counseling or therapy, please tell us what you found helpful and what you found not helpful: