Name and Date ___________________________________________________

 

Description of Symptoms

(Confidential)

Please check all the boxes which apply to you even if it seems unrelated to your current   counseling issue.

CHANGE IN:

ñ Sleep ___increase  ___ decrease

             average hours/night _________

ñ Trouble falling asleep

ñ Trouble staying asleep

ñ Appetite ____ increase ____ decrease

ñ Health (explain) ___________

ñ Weight

      Lost or gained (circle) How Much? ______

                                     Over how Long? ______

ñ Physical Energy

             (explain) ______________

 

 

RECENT HISTORY OF:

ñ Nausea and Vomiting

ñ Diarrhea

ñ Shortness of Breath

ñ Rapid Breathing

ñ Severe headache

ñ Confusion

ñ Bleeding

ñ Crying Spells

ñ Other Illness:  __________

 

 

THOUGHTS OF:

ñ Harming Self

             date of most resent episode _______

             did you have a plan?  ____________

             if yes, please describe ____________

ñ Harming Others

ñ Suicide

ñ Self Manipulation (cutting, burning)

             (explain )_______________________

 

 

 

LIFE CHANGE:

ñ Death in Family

             Relationship _________When _______

ñ Divorce/Separation of

        parents/guardian/spouse

ñ Loss of Friend

ñ Physical Illness

ñ Other _______________

 

FEAR OF:

ñ Death

             _____ your own ____someone else

ñ Being Alone

ñ Animals

ñ A Place or Situation

ñ Aids

ñ “Going Crazy”

ñ Germs

 

CONFLICT WITH:

ñ Spouse

ñ Children

ñ Parents

ñ Brother or Sister

ñ Another student/peer

ñ Girl/boy Friend

ñ School Authority

ñ Police

             (explain)________________________

 

PROBLEM WITH:

ñ Time Management

ñ Work

ñ Class Work

ñ Homework

ñ Social relationships

ñ Family Relationships

                         

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