tired/fatigued (partner’s Sadness/depression Feeling Codependency substance abuse) of appetite Loss Hopelessness Confusion difficulty distracted Sleep Easily spacey/detached from Feeling Attention/concentration Anger one’s surroundings (cutting, burning, Overeating Self-injury spells scratching, pulling out hair) Crying gain/loss Weight Adultery/infidelity Hyperactivity disorder Eating empty/dissatisfied Feeling Excessive like a failure Feeling thoughts/fears trusting others Obsessive Difficulty image headache Body Chronic self-esteem Low Gambling making decisions Difficulty pain/discomfort Physical (germs, heights, Phobias judgment Poor issues Medical confined places, etc.) concerned about what with elder parents Overly Issues due to death Loss/grief other people think of joy/satisfaction in life Lack Impulsiveness Irritability withdrawal/isolation Social behaviors Compulsive with authority Trouble Stress checking, etc.) problems/court Legal Loneliness Housework/home involvement disorganized Feeling maintenance Separation/divorce with Problems of inferiority Feelings swings Mood taking responsibility Trouble sensitive Overly Alcohol problems, PMS, Menstrual conflicts with others Frequent Marijuana menopause accepting/making Difficulty Cocaine of motivation Lack changes drugs Prescription with special needs Children behavior Risky/dangerous illicit substances Other Perfectionism friends Few Restlessness/fidgety Religion/spirituality Smoking Negativity temper Bad Inappropriate/uncomfortable forgiving Difficulty sexual thoughts/urges Self-control Nightmares of pets Procrastination Cruelty/neglect Unemployment Hallucinations from childhood Issues Please take a moment and review the issues or problems you have noted on this questionnaire. Which three items are you most concerned about. In other words, which three concerns would you most like to have addressed in your treatment? 1. 2. 3. VII. Substance Use and Addictive Behaviors
Sadness/depression Loss of appetite Sleep difficulty Attention/concentration Overeating Weight gain/loss Eating disorder Excessive Difficulty trusting others Low self-esteem Physical pain/discomfort Medical issues Issues with elder parents Lack of joy/satisfaction in life Social withdrawal/isolation Stress Loneliness Feeling disorganized Problems with Alcohol Marijuana Cocaine Prescription drugs Other illicit substances Restlessness/fidgety Negativity Difficulty forgiving Nightmares Unemployment Feeling tired/fatigued Hopelessness Easily distracted Anger Self-injury (cutting, burning, scratching, pulling out hair) Hyperactivity Obsessive thoughts/fears Chronic headache Difficulty making decisions Poor judgment Overly concerned about what other people think Irritability Trouble with authority Legal problems/court involvement Separation/divorce Mood swings Overly sensitive Frequent conflicts with others Difficulty accepting/making changes Risky/dangerous behavior Few friends Smoking Inappropriate/uncomfortable sexual thoughts/urges Cruelty/neglect of pets Issues from childhood Codependency (partner’s substance abuse) Confusion Feeling spacey/detached from one’s surroundings Crying spells Adultery/infidelity Feeling empty/dissatisfied Feeling like a failure Body image Gambling Phobias (germs, heights, confined places, etc.) Loss/grief due to death Impulsiveness Compulsive behaviors checking, etc.) Housework/home maintenance Feelings of inferiority Trouble taking responsibility Menstrual problems, PMS, menopause Lack of motivation Children with special needs Perfectionism Religion/spirituality Bad temper Self-control Procrastination Hallucinations Please take a moment and review the issues or problems you have noted on this questionnaire. Which three items are you most concerned about. In other words, which three concerns would you most like to have addressed in your treatment? 1. 2. 3. VII. Substance Use and Addictive Behaviors
Intake_Evaluation_Form_2012.docx