Continued: List of Symptoms extreme fatigue fears fetishes finances friends guilt headaches health problems inferiority feelings insomnia loneliness making decisions marriage memory my thoughts nervousness nightmares obsessive thinking overweight painful thoughts panic attacks phobias relationships sadness self-esteem separation sexual problems short temper shyness sleep stress suicidal thoughts work Please indicate how the issue(s) for which you are seeking treatment are affecting the following areas of your life: Marriage / Relationship: 1 - No effect 2 Little effect 3 Some effect – – 4 Much effect 5 Significant effect Not Applicable – – Family: 1 - No effect 2 Little effect 3 Some effect – – 4 Much effect 5 Significant effect Not Applicable – – Job/school performance: 1 - No effect 2 Little effect 3 Some effect – – 4 Much effect 5 Significant effect Not Applicable – –
Continued: List of Symptoms extreme fatigue fears fetishes finances friends guilt headaches health problems inferiority feelings insomnia loneliness making decisions marriage memory my thoughts nervousness nightmares obsessive thinking overweight painful thoughts panic attacks phobias relationships sadness self-esteem separation sexual problems short temper shyness sleep stress suicidal thoughts work Please indicate how the issue(s) for which you are seeking treatment are affecting the following areas of your life: Marriage / Relationship: 1 - No effect 2 – Little effect 3 – Some effect 4 – Much effect 5 – Significant effect Not Applicable Family: 1 - No effect 2 – Little effect 3 – Some effect 4 – Much effect 5 – Significant effect Not Applicable Job/school performance: 1 - No effect 2 – Little effect 3 – Some effect 4 – Much effect 5 – Significant effect Not Applicable
adult-intake-form-ud.docx