What do you consider to be your strengths? (personal, family, vocational, recreation, social, cultural, community resources, etc.)_______________________________________________________________ Is your current issue affecting your academic, work, or social functioning? Please explain. Please list your and expectations for counseling. Symptom Checklist Please the following words or phrases you feel apply to you or your life: Headaches Difficulty keeping a job Memory problems □ □ □ Heart Palpitations Poor academic Financial problems □ □ □ Drug Use performance Nightmares □ □ Shy Sleep problems Feelings of emptiness □ □ □ Feelings of Worthlessness Restless Poor appetite □ □ □ Indecisive Regrets from past Dizziness □ □ □ Feelings of panic Guilt Lonely □ □ □ Unable to relax Stomach/digestive issues Nervous □ □ □ Trembling Excessive worry Fainting spells □ □ □ Confused Few friends Depressed □ □ □ Hopeless Disturbing thoughts Moody □ □ □ Things seem surreal Poor concentration Sexual concerns □ □ □ Relationship issues Angry Fear □ □ □ Anxiety Recent loss(es) Chronic pain □ □ □ Fatigue Impulsive Abusive behavior □ □ □ Parental concerns Irritability please list: □ □ □ Illness of a family member Eating Disorder □ □ □
What do you consider to be your strengths? (personal, family, vocational, recreation, social, cultural, community resources, etc.)_______________________________________________________________ Is your current issue affecting your academic, work, or social functioning? Please explain. Please list your and expectations for counseling. Symptom Checklist Please the following words or phrases you feel apply to you or your life: □ Headaches □ Heart Palpitations □ Drug Use □ Shy □ Feelings of Worthlessness □ Indecisive □ Feelings of panic □ Unable to relax □ Trembling □ Confused □ Hopeless □ Things seem surreal □ Relationship issues □ Anxiety □ Fatigue □ Parental concerns □ Illness of a family member □ Difficulty keeping a job □ Poor academic performance □ Sleep problems □ Restless □ Regrets from past □ Guilt □ Stomach/digestive issues □ Excessive worry □ Few friends □ Disturbing thoughts □ Poor concentration □ Angry □ Recent loss(es) □ Impulsive □ Irritability □ Eating Disorder □ Memory problems □ Financial problems □ Nightmares □ Feelings of emptiness □ Poor appetite □ Dizziness □ Lonely □ Nervous □ Fainting spells □ Depressed □ Moody □ Sexual concerns □ Fear □ Chronic pain □ Abusive behavior □ please list: □
child_intake_revised.2.docx