Emotional Concerns
ÿ feeling anxious or uptight
ÿ excessive worrying
ÿ not being able to relax
ÿ feeling panicky
ÿ unable to calm yourself down
ÿ dwelling on certain thoughts or images
ÿ fearing something terrible is about to happen
ÿ avoiding certain thoughts or feelings
ÿ having strong fears
ÿ worrying about a nervous breakdown
ÿ feeling out of control
ÿ fears of being alone or abandoned
ÿ feeling guilty
ÿ having nightmares
ÿ flashbacks
ÿ troubling or painful memories
ÿ missing periods of time - can’t remember
ÿ trouble remembering things
ÿ feeling numb instead of upset
ÿ feeling detached from all or part of your body
ÿ having obsessive/ruminating thoughts
ÿ feeling unreal, strange or foggy
Behavioral and Physical Concerns
ÿ not having an appetite
ÿ having obsessive behaviors such as:
ÿ hand-washing, checking, counting, etc.
ÿ eating in binges
ÿ self induced vomiting for weight control
ÿ using laxatives for weight control
ÿ eating too much
ÿ eating too little
Individual Problem Checklist
ÿ feeling unmotivated
ÿ loss of interest in many things
ÿ having trouble concentrating
ÿ having trouble making decisions
ÿ feeling the future looks hopeless
ÿ feeling worthless or like a failure
ÿ being unhappy all the time
ÿ dissatisfied with physical appearance
ÿ feeling self critical or blaming yourself
ÿ having negative thoughts
ÿ crying often
ÿ feeling empty
ÿ withdrawing inside yourself
ÿ thinking too much about death
ÿ thoughts of hurting yourself
ÿ thoughts of killing yourself
ÿ frequent mood swings
ÿ feeling resentful or angry
ÿ feeling irritable or frustrated
ÿ feeling rage
ÿ feeling like hurting someone
ÿ losing weight - how much?
ÿ gaining weight - how much?
ÿ avoiding being with people
ÿ being tired and lacking energy
ÿ excessive exercise
Behavioral and Physical Concerns Continued
ÿ trouble finishing things
ÿ cutting or harming self
ÿ trouble sleeping
ÿ trouble falling asleep
ÿ early morning awakening
ÿ sleeping too much
ÿ sleeping too little
ÿ number of hours I usually sleep:
ÿ aggressive toward others
ÿ impulsive reactions
ÿ working too hard
ÿ using alcohol too much
ÿ being alcoholic
ÿ using drugs
ÿ driving under the influence
ÿ blackouts - after drinking
ÿ lack of exercise
Intimate Relationship Concerns
ÿ feeling misunderstood in relationship
ÿ not feeling close to partner
ÿ trouble communicating with partner
ÿ not trusting partner
ÿ lack of respect by partner
ÿ partner being secretive
ÿ lack of fairness in relationship
ÿ problems with dividing household tasks
ÿ disagreeing about children
ÿ lack of affection
ÿ unsatisfactory sexual relationship
ÿ lack of time together
ÿ lack of shared interests
ÿ lack of positive interaction
ÿ lack of time with other couples
ÿ jealousy in relationship frequent arguments
ÿ not having leisure activities
ÿ smoking cigarettes
ÿ often spending in binges
ÿ Have you ever felt you ought to cut down on your
ÿ drinking or drug use? Yes No
ÿ Have people annoyed you by criticizing your drinking
ÿ or drug use? Yes No
ÿ Have you ever felt bad or guilty about your drinking
ÿ or drug use? Yes No
ÿ Have you ever had a drink or used drugs first thing in
ÿ the morning to steady your nerves or to get rid of a
ÿ hangover? Yes No
ÿ trouble resolving conflict
ÿ partner being demanding and controlling
ÿ partner putting you down
ÿ violent arguments
ÿ emotional abuse in relationship
ÿ physical abuse in relationship
ÿ sexual abuse in relationship
ÿ partner having alcohol or drug problem
ÿ self or partner having an affair
ÿ feeling uncommitted to relationship
ÿ wanting to separate
ÿ discussing separating or divorce
ÿ problems with in-laws
ÿ problems with ex-partner
ÿ problems with step parents
ÿ children having special problems
Sexual Concerns
ÿ worrying about getting pregnant
ÿ having miscarriage(s)
ÿ choice of birth control and/or abortion
ÿ not able to become pregnant
ÿ not enjoying sexual affection
ÿ too tired to have sex
ÿ too anxious to have sex
ÿ feeling a lack of sexual desire
ÿ wanting to have sex more often
ÿ feeling neglected sexually
When Growing Up to Present Time
ÿ being physically abused - by whom?
ÿ being emotionally abused - by whom?
ÿ being sexually abused - by whom?
ÿ having an alcoholic parent - which?
ÿ having a drug abusing parent - which?
ÿ having a depressed parent - which?
ÿ having a parent with emotional problems -
ÿ which?
ÿ having parents separate or divorce -
ÿ your age at time of divorce?
Stresses During the Past Several Years
ÿ death of family member or friend - who?
ÿ birth or adoption of child
ÿ self or family member hospitalized - who?
ÿ moved/changed address
ÿ being harassed or assaulted
ÿ frequent family or couple arguments
ÿ separation/divorce
