SYMPTOMS: Please any problems that either you have had in the past or are currently having. Now Past Bored easily Change in appetite (more or less) Learning difficulties Feeling sad lose things Crying spells Excessive dieting/exercise Too little sleep (falling or staying asleep) Obsessed with losing weight Sleep more than usual Use of laxatives Fatigue Engage in self-induced vomiting Loss of interest &/or pleasure Eating things that are not food Avoiding friends or family Vandalism Expect failure Fire-setting Decreased concentration Lack of remorse for wrong-doing Thoughts of death Selfish Cutting or burning oneself Bullies/gets in fights Suicide plan or attempt Lying Depression Truancy Often sick Theft Loneliness Argumentative/sudden anger Slow moving Defiant of authority Hopelessness Temper tantrums Confusion Stubborn Worthlessness adults Friendly Afraid to leave a loved one Lack of confidence/Low self-esteem Easily embarrassed Guilt Upset by minor changes Reckless or dangerous behavior Feeling detached from one’s body Racing thoughts Feelings of unreality Pressured speech See or hear things others don’t Inflated self-esteem Believe things others tell you aren’t true Obsessive thoughts Fear of strangers Compulsive or repetitive behavior Difficulty trusting Marital/family problems Believe others are out to get you Sexual problems Intrusive thoughts Relationship problems Avoid things related to traumatic event Long term memory problems Startle easily Short term memory problems Flashbacks Wound up or tense more days than not Nightmares attacks symptoms not mentioned above Irritable Anxiety Easy Muscle tension How do your symptoms affect your life? Irrational fear of something or someone Talking/acting w/out thinking Fidgety, restless, overactive Difficulty paying attention Frequent day dreams
SYMPTOMS: Please any problems that either you have had in the past or are currently having. Now Past Change in appetite (more or less) Feeling sad Crying spells Too little sleep (falling or staying asleep) Sleep more than usual Fatigue Loss of interest &/or pleasure Avoiding friends or family Expect failure Decreased concentration Thoughts of death Cutting or burning oneself Suicide plan or attempt Depression Often sick Loneliness Slow moving Hopelessness Confusion Worthlessness Friendly Lack of confidence/Low self-esteem Guilt Reckless or dangerous behavior Racing thoughts Pressured speech Inflated self-esteem Obsessive thoughts Compulsive or repetitive behavior Marital/family problems Sexual problems Relationship problems Long term memory problems Short term memory problems Wound up or tense more days than not attacks Irritable Anxiety Easy Muscle tension Irrational fear of something or someone Talking/acting w/out thinking Fidgety, restless, overactive Difficulty paying attention Frequent day dreams Bored easily Learning difficulties lose things Excessive dieting/exercise Obsessed with losing weight Use of laxatives Engage in self-induced vomiting Eating things that are not food Vandalism Fire-setting Lack of remorse for wrong-doing Selfish Bullies/gets in fights Lying Truancy Theft Argumentative/sudden anger Defiant of authority Temper tantrums Stubborn adults Afraid to leave a loved one Easily embarrassed Upset by minor changes Feeling detached from one’s body Feelings of unreality See or hear things others don’t Believe things others tell you aren’t true Fear of strangers Difficulty trusting Believe others are out to get you Intrusive thoughts Avoid things related to traumatic event Startle easily Flashbacks Nightmares symptoms not mentioned above How do your symptoms affect your life?
2018_ADULT_INTAKE.docx