Symptoms List

Name

All sections are required. If nothing applies in a section, select the "none listed" check box.

Current Emotional Disturbances

Current Interpersonal Disturbances

Current Stressors / Anxiety

Check all that apply

Restless, feeling keyed up or on edge

Unwanted persistent, intrustive thoughts

Excessive stress, worry

Unmanageable anxiety and/or fears

Anxiety attacks / Panic Attacks

Discomfort in social settings

Fear of worst case scenario

Feeling out of control

None listed

Current Self-esteem / Body Image

Check all that apply

Negative self-talk

Perfectionsim

Question my purpose in life

Hate my body

Uncomfortable in my own skin

Low self confidence

Low self-esteem

Rarely speak out or share my opinion

None listed

Current Physical Health Concerns

Current Thought Patterns

Current Habitual Behaviors

Abuse / Trauma Assessment

Grief and Loss Assessment

Suicide / Self-harm Assessment

Check all that apply

Active / current thoughts of suidice

Past thoughts of suicide

Past attempt(s) of suicide

Feeling others would be better off if I were dead

Lack of motivation for living

Active / current self-harming behaviors

Past self-harm (cutting, hitting, hair-pulling, etc)

None listed

Physical Harm Assessment

Check all that apply

I fear for the safety of my family

I believe someone intends to physically harm me

I have persistent thoughts of harming another person

I have weapons in the home

None listed

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