Self Checklist: Identify Therapy Concerns and Issues

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.

 
Mild Concern / Major Issue
Abuse - physical, sexual, emotional, neglect
1  2  3  4  5
Aggression, violence
1  2  3  4  5
Alcohol use
1  2  3  4  5
Anger, hostility, arguing, irritability
1  2  3  4  5
Anxiety, nervousness
1  2  3  4  5
Attention, concentration, distractibility
1  2  3  4  5
Body image
1  2  3  4  5
Childhood issues (your own)
1  2  3  4  5
Confusion
1  2  3  4  5
Compulsions
1  2  3  4  5
Conflicts with others
1  2  3  4  5
Decisions: indecision, mixed feelings, putting off
1  2  3  4  5
Delusions (false ideas)
1  2  3  4  5
Dependence
1  2  3  4  5
Depression, low mood, sadness, crying
1  2  3  4  5
Drug use - prescriptions, over the counter, illegal drugs
1  2  3  4  5
Eating - overeating, undereating, appetite issues, vomiting
1  2  3  4  5
Emptiness
1  2  3  4  5
Exercise
1  2  3  4  5
Fatigue, tiredness, low energy
1  2  3  4  5
Fears, phobias
1  2  3  4  5
Feelings of failure
1  2  3  4  5
Friendships
1  2  3  4  5
Gambling
1  2  3  4  5
Grieving, mourning, deaths, losses, divorce
1  2  3  4  5
Guilt
1  2  3  4  5
Headaches, other kinds of pains
1  2  3  4  5
Housework/chores - quality, schedules, sharing duties
1  2  3  4  5
Inferiority feelings
1  2  3  4  5
Loneliness
1  2  3  4  5
Marital conflict, distance, infidelity, disappointments
1  2  3  4  5
Memory problems
1  2  3  4  5
Menstrual problems, PMS, menopause
1  2  3  4  5
Mood swings
1  2  3  4  5
Motivation, difficulty completing tasks
1  2  3  4  5
Nervousness, tension
1  2  3  4  5
Obsessions, compulsions (repetitive thoughts/actions)
1  2  3  4  5
Panic or anxiety attacks
1  2  3  4  5
Perfectionism
1  2  3  4  5
Pessimism
1  2  3  4  5
Procrastination
1  2  3  4  5
Relationship problems (friends, relatives, work)
1  2  3  4  5
Relationship problems (spouse/partner)
1  2  3  4  5
Risk-taking, poor judgement
1  2  3  4  5
Self esteem
1  2  3  4  5
Self-neglect, poor self-care
1  2  3  4  5
Sensitivity to rejection
1  2  3  4  5
Sexual issues, problems, conflicts, desire differences
1  2  3  4  5
Shyness, social anxiety
1  2  3  4  5
Sleep problems - too much, too little, insomnia, nightmares
1  2  3  4  5
Smoking and tobacco use
1  2  3  4  5
Spiritual, religious, moral, ethical issues
1  2  3  4  5
Stress, relaxation, stress management, tension
1  2  3  4  5
Suspiciousness
1  2  3  4  5
Suicidal thoughts/history of suicidality
1  2  3  4  5
Thought disorganization and confusion
1  2  3  4  5
Threats, violence
1  2  3  4  5
Withdrawal, isolating
1  2  3  4  5
Work problems, overworking, dissatisfaction, ambition
1  2  3  4  5
I have no problems or issues to work on in therapy (circle if this applies to you)


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.