PLEASE RATE ANY SYMPTOM/S THAT YOU ARE OR HAVE EXPERIENCED THAT YOU THINK CREATES CONFLICT IN YOUR LIFE AND WOULD LIKE TO WORK ON IN SESSIONS WITH YOUR THERAPIST.

SYMPTOMS

Depression

With 0 being "Never" and 10 being "High"

I have been depressed for:

Anxiety

With 0 being "Never" and 10 being "High"

Panic Disorder

With 0 being "Never" and 10 being "High"

Mood Disorder

With 0 being "Never" and 10 being "Always"

If 5 OR ABOVE IS CHOSEN please complete the mood disorder questionnaire.

Manic Episodes

With 0 being "Never" and 10 being "High"

Anger

With 0 being "Never" and 10 being "High"

If any of the above areas are checked, please complete Trauma/PTSD questionnaire

ADHD

With 0 being "Never" and 10 being "High" "I experience ADHD Symptoms ______"

If 5 or above is chosen please complete ADHD questionnaire.

Obsessions/Compulsions

With 0 being "Never" and 10 being "High"

Aggression

With 0 being "Never" and 10 being "Always"

Grief/Bereavement

With 0 being "Never" and 10 being "Always"

Guilt

With 0 being "Never" and 10 being "Always"

Jealousy

With 0 being "Never" and 10 being "Always"

Shame

With 0 being "Never" and 10 being "Always"

Insomnia

With 0 being "Never" and 10 being "Always" "I have trouble sleeping _____"

Paranoia

With 0 being "Never" and 10 being "Always"

Self Esteem

With 0 being "Never" and 10 being "Always" "I feel good about myself _____"

Relationship Problems

With 0 being "No Problem" and 10 being "Big Problem"

Family Problems

With 0 being "Never" and 10 being "Always"

Decision Making

With 0 being "Never" and 10 being "Always" "I have trouble making decisions _____"

Social Interaction

With 0 being "Never" and 10 being "Always" "I engage in social activities with others _____"

Please initial here

Client Symptom Rating