Adult Checklist of Concerns

Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other concerns or issues.” You may add a note or details in the space next to the concerns checked. (For a child, mark any of these and then complete the “Child Checklist of Characteristics.”)

  • I have no problem or concern bringing me here
  • Abuse—physical, sexual, emotional, neglect (of children or elderly), cruelty to animals
  • Aggression, violence
  • Alcohol use
  • Anger, hostility, arguing, irritability
  • Anxiety, nervousness
  • Attention, concentration, distractibility
  • Career concerns, goals, and choices
  • Childhood issues (your own childhood)
  • Children, child management, child care, parenting
  • Codependence
  • Confusion
  • Compulsions
  • Custody of children
  • Decision making, indecision, mixed feelings, putting off decisions
  • Delusions (false ideas)
  • Dependence
  • Depression, low mood, sadness, crying
  • Divorce, separation
  • Drug use—prescription medications, over-the-counter medications, street drugs
  • Eating problems—overeating, undereating, appetite, vomiting (see also “Weight and diet issues”)
  • Emptiness
  • Failure
  • Fatigue, tiredness, low energy
  • Fears, phobias
  • Financial or money troubles, debt, impulsive spending, low income
  • Friendships
  • Gambling
  • Grieving, mourning, deaths, losses, divorce
  • Guilt
  • Headaches, other kinds of pains
  • Health, illness, medical concerns, physical problems, symptoms
  • Inferiority feelings
  • Interpersonal conflicts
  • Impulsiveness, loss of control, outbursts
  • Irresponsibility
  • Judgment problems, risk taking
  • Legal matters, charges, suits
  • Loneliness
  • Marital conflict, distance/coldness, infidelity/affairs, remarriage
  • Memory problems
  • Menstrual problems, PMS, menopause
  • Mood swings
  • Motivation, laziness
  • Nervousness, tension
  • Obsessions, compulsions (thoughts or actions that repeat themselves)
  • Oversensitivity to rejection
  • Panic or anxiety attacks
  • Perfectionism
  • Pessimism
  • Procrastination, work inhibitions, laziness
  • Relationship problems
  • School problems (see also “Career concerns . . .”)
  • Self-centeredness
  • Self-esteem
  • Self-neglect, poor self-care
  • Sexual issues, dysfunctions, conflicts, desire differences, other (see also “Abuse”)
  • Shyness, oversensitivity to criticism
  • Sleep problems—too much, too little, insomnia, nightmares
  • Smoking and tobacco use
  • Stress, relaxation, stress management, stress disorders, tension
  • Suspiciousness
  • Suicidal thoughts
  • Temper problems, self-control, low frustration tolerance
  • Thought disorganization and confusion
  • Threats, violence
  • Weight and diet issues
  • Withdrawal, isolating
  • Work problems, employment, workaholism/overworking, can’t keep a job

Any other concerns or issues:

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Please look back over the concerns you have checked off and choose the one that you most want help with. It is:

 

 

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