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
divorce issues
serious physical illness (self or family)
health concerns (self or family)
fatigue/low energy
death of family member or friend
anxiety/worry/nervousness
panic attacks
reluctant to leave home or familiar neighborhood
___
___
___
___
___
___
___
___
___
confusion
much fantasy or daydreaming
hyperactivity/attention problems
headaches/stomach aches
sexual problems
sexual identity concerns
identity concerns
feelings of unreality
obsessive thoughts/excessive fears
___
___
___
___
___
___
___
perfectionism
guilt/shame feelings
trouble sleeping
depressed mood/sadness
suicidal thoughts
self-injury
eating habits
___
___
___
___
___
___
___
unusual thoughts or perceptions
excessive energy
impulsive decisions or actions
difficulty trusting others
low self-esteem
avoidance of conflict
withdrawn, isolating
___ spending habits
___ concerns about behavior/habits/compulsions
___ concern about alcohol/drug use
___ shy/uneasy around others
___ fear of failure
___ fear of disapproval
___ concern about lying or dishonesty with others
___ need to please others and be liked
___ anger/irritability
___ mood swings
___ loss of temper/outbursts
___ difficulty saying “no” to others or asserting self
___ difficulty making independent decisions
___ feelings of futility/loss of hope
___ aggressive/violent behaviors
___ loss of joy in living
___ physical abuse of self (current or past)
___ verbal/emotional abuse (current or past)
___ physical abuse of others
___ 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)
1
minimal
2
3
moderate
4
5
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.
1
none
2
3
some, but
not adequate
4
5
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: