Please mark all the items below that apply, circling their level of severity and note the top three with which you'd most like help.
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Abuse - physical, sexual, emotional, neglect |
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Aggression, violence |
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Alcohol use |
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Anger, hostility, arguing, irritability |
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Anxiety, nervousness |
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Attention, concentration, distractibility |
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Body image |
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Childhood issues (your own) |
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Confusion |
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Compulsions |
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Conflicts with others |
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Decisions: indecision, mixed feelings, putting off |
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Delusions (false ideas) |
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Dependence |
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Depression, low mood, sadness, crying |
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Drug use - prescriptions, over the counter, illegal drugs |
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Eating - overeating, undereating, appetite issues, vomiting |
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Emptiness |
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Exercise |
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Fatigue, tiredness, low energy |
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Fears, phobias |
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Feelings of failure |
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Friendships |
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Gambling |
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Grieving, mourning, deaths, losses, divorce |
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Guilt |
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Headaches, other kinds of pains |
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Housework/chores - quality, schedules, sharing duties |
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Inferiority feelings |
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Loneliness |
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Marital conflict, distance, infidelity, disappointments |
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Memory problems |
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Menstrual problems, PMS, menopause |
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Mood swings |
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Motivation, difficulty completing tasks |
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Nervousness, tension |
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Obsessions, compulsions (repetitive thoughts/actions) |
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Panic or anxiety attacks |
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Perfectionism |
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Pessimism |
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Procrastination |
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Relationship problems (friends, relatives, work) |
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Relationship problems (spouse/partner) |
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Risk-taking, poor judgement |
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Self esteem |
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Self-neglect, poor self-care |
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Sensitivity to rejection |
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Sexual issues, problems, conflicts, desire differences |
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Shyness, social anxiety |
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Sleep problems - too much, too little, insomnia, nightmares |
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Smoking and tobacco use |
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Spiritual, religious, moral, ethical issues |
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Stress, relaxation, stress management, tension |
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Suspiciousness |
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Suicidal thoughts/history of suicidality |
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Thought disorganization and confusion |
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Threats, violence |
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Withdrawal, isolating |
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Work problems, overworking, dissatisfaction, ambition |
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I have no problems or issues to work on in therapy (circle if this applies to you) |
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Please print out and bring with you to our first therapy session so we can discuss your urgent priorities and what will be most helpful to you.