Self esteem Personal identity MOOD/FEELINGS /BEHAVIOR Adjustment to college Now/Past ADD, ADHD Financial problems Anxiety, worries, panic Coping with stress Depression, sadness, apathy Managing multiple responsibilities Feeling hopeless or worthless Sleep problems Mood swings Spirituality/religion/values issues Obsessive thoughts, compulsive behaviors Bereavement, loss, grief Irrational feelings, thoughts, behaviors INTERPERSONAL SKILLS Loss of interest in things Making or keeping friends Suicidal feelings / thoughts Shyness/anxiety in social situations Suicide attempt Multicultural concerns Irritability (_ ) and/or Anger ( _) Conflict Resolution Impulsive behavior RELATIONSHIPS (Current Concerns) Psychiatric / psychological disability Relationship conflict Self Harm / Cutting up FAMILY Improving relationship Parental conflict / divorce / separation Relationship abuse / violence Conflict with parent ACADEMIC Family financial difficulty Motivation Family violence Problems with studying Sibling concerns Learning disabilities Marital concerns (including sep/div) Time management Child concerns Test taking problems ABUSE / VIOLENCE (Circle all that apply) Performance anxiety Emotional abuse Missing classes Sexual abuse Career Planning Sexual assault (_ ) Rape (_ ) Conflict with MC faculty/staff/admin Physical abuse DISCRIMINATION / HARASSMENT DUE TO Threat / Assault Sexual harassment / Stalking SEX / GENDER Taunting / Bullying Sexual orientation / Gender identity Race / Ethnicity Sexual behavior Gender Sexual responsiveness or performance Sexual orientation ADDICTION-RELATED CONCERNS Disability Alcohol: (self) (other) PHYSICAL HEALTH / ILLNESS Other substances: (self) (other) Coping with illness: (self) (other) DUI Physical disability concerns Gambling problem: (self) (other) Other health: Support for recovery EATING Family alcoholism / Drug abuse Overeating Computer game / Internet /TV overuse Binging / purging DISCIPLINE / LEGAL / CRIMINAL Under-eating or restricting Victim of crime Weight Witness to crime Body image concerns legal / criminal concern OTHER THINGS IMPORTANT TO KNOW ABOUT YOU:
Self esteem Personal identity Adjustment to college Financial problems Coping with stress Managing multiple responsibilities Sleep problems Spirituality/religion/values issues Bereavement, loss, grief INTERPERSONAL SKILLS Making or keeping friends Shyness/anxiety in social situations Multicultural concerns Conflict Resolution RELATIONSHIPS (Current Concerns) Relationship conflict up Improving relationship Relationship abuse / violence ACADEMIC Motivation Problems with studying Learning disabilities Time management Test taking problems Performance anxiety Missing classes Career Planning Conflict with MC faculty/staff/admin DISCRIMINATION / HARASSMENT DUE TO Sexual harassment / Stalking Taunting / Bullying Race / Ethnicity Gender Sexual orientation Disability PHYSICAL HEALTH / ILLNESS Coping with illness: (self) (other) Physical disability concerns Other health: EATING Overeating Binging / purging Under-eating or restricting Weight Body image concerns MOOD/FEELINGS /BEHAVIOR Now/Past ADD, ADHD Anxiety, worries, panic Depression, sadness, apathy Feeling hopeless or worthless Mood swings Obsessive thoughts, compulsive behaviors Irrational feelings, thoughts, behaviors Loss of interest in things Suicidal feelings / thoughts Suicide attempt Irritability (_ ) and/or Anger ( _) Impulsive behavior Psychiatric / psychological disability Self Harm / Cutting FAMILY Parental conflict / divorce / separation Conflict with parent Family financial difficulty Family violence Sibling concerns Marital concerns (including sep/div) Child concerns ABUSE / VIOLENCE (Circle all that apply) Emotional abuse Sexual abuse Sexual assault (_ ) Rape (_ ) Physical abuse Threat / Assault SEX / GENDER Sexual orientation / Gender identity Sexual behavior Sexual responsiveness or performance ADDICTION-RELATED CONCERNS Alcohol: (self) (other) Other substances: (self) (other) DUI Gambling problem: (self) (other) Support for recovery Family alcoholism / Drug abuse Computer game / Internet /TV overuse DISCIPLINE / LEGAL / CRIMINAL Victim of crime Witness to crime legal / criminal concern OTHER THINGS IMPORTANT TO KNOW ABOUT YOU:
current_concerns_2016.docx