Check all that apply (to be completed by both the adolescent and parent/guardian) Depression Making/keeping friends Low energy Arguing with others Low self-esteem Performing unusual rituals or habits Poor concentration Impulsiveness Lack of interest/enjoyment in life Excessive behaviors (Examples: spending, gambling) Feeling hopeless Delusions/hallucinations (Thinking/believing or seeing/hearing Feeling worthless unusual things) Feeling guilty or shameful Sexual problems/behavior Sleep changes (more/less) Self injurious behaviors Loneliness Shyness Bad dreams/nightmares Social skills Feeling Ignored or abandoned Social support (family/friends) Appetite changes (more/less) Stealing Mood swings Strange, weird, or peculiar behavior Thoughts of hurting self Confusion/can’t think clearly Thoughts of hurting others Feeling “not real” Isolating from others/social withdrawal Feeling detached from yourself Feelings of sadness/loss Feeling “hyper” Weight problems Financial problems Stress Grief/bereavement Anxiety/tension/worry Health problems Panic attacks Impact of your problems on others Heart racing Losing track of time Chest pain or heaviness Problems with memory Chills/hot flashes Unpleasant thoughts that won’t go away Tingling/numbness Bothered by recurring thoughts Pain School/educational problems or indecision Fear of dying Destruction of property Fear of going “crazy” Self-criticism Nausea Family problems Fears or phobias Marital/relationship problems Obsessions/compulsions Parent/child problems Thoughts racing Use of alcohol Disorganization Use of drugs Procrastination Blackouts Can’t hold onto an idea Physical abuse Anger/frustration Sexual abuse Suspiciousness or mistrustfulness Partner abuse Problems trusting others Trouble with the law Easily irritated/annoyed Experienced/witnessed trauma Aggressiveness Loss/death of someone close Perfectionist behavior Impulsive behaviors Lying Other (please describe): Current Life Experiences My adolescent lives in:
Check all that apply (to be completed by both the adolescent and parent/guardian) Depression Low energy Low self-esteem Poor concentration Lack of interest/enjoyment in life Feeling hopeless Feeling worthless Feeling guilty or shameful Sleep changes (more/less) Loneliness Bad dreams/nightmares Feeling Ignored or abandoned Appetite changes (more/less) Mood swings Thoughts of hurting self Thoughts of hurting others Isolating from others/social withdrawal Feelings of sadness/loss Weight problems Stress Anxiety/tension/worry Panic attacks Heart racing Chest pain or heaviness Chills/hot flashes Tingling/numbness Pain Fear of dying Fear of going “crazy” Nausea Fears or phobias Obsessions/compulsions Thoughts racing Disorganization Procrastination Can’t hold onto an idea Anger/frustration Suspiciousness or mistrustfulness Problems trusting others Easily irritated/annoyed Aggressiveness Perfectionist behavior Lying Making/keeping friends Arguing with others Performing unusual rituals or habits Impulsiveness Excessive behaviors (Examples: spending, gambling) Delusions/hallucinations (Thinking/believing or seeing/hearing unusual things) Sexual problems/behavior Self injurious behaviors Shyness Social skills Social support (family/friends) Stealing Strange, weird, or peculiar behavior Confusion/can’t think clearly Feeling “not real” Feeling detached from yourself Feeling “hyper” Financial problems Grief/bereavement Health problems Impact of your problems on others Losing track of time Problems with memory Unpleasant thoughts that won’t go away Bothered by recurring thoughts School/educational problems or indecision Destruction of property Self-criticism Family problems Marital/relationship problems Parent/child problems Use of alcohol Use of drugs Blackouts Physical abuse Sexual abuse Partner abuse Trouble with the law Experienced/witnessed trauma Loss/death of someone close Impulsive behaviors Other (please describe): Current Life Experiences My adolescent lives in:
adolescent-intake__revised_7.19.16_.docx