Name: _____________________________________ Date:_________________

Individual Problem Checklist

Directions:
Put a number next to any item which you experience. 1=mildly, 2=moderately, 3=severely

Emotional Concerns ____feeling depressed or sad

____feeling anxious or uptight ____being tired or lacking energy
____excessive worrying ____feeling unmotivated
____not being able to relax ____loss of interest in many things
____feeling panicky ____having trouble concentrating
____unable to calm yourself down ____having trouble making decisions
____dwelling on certain thoughts or images ____feeling the future looks hopeless
____fearing something terrible about to happen ____feeling worthless or a failure
____avoiding certain thoughts or feelings ____being unhappy all the time
____having strong fears ____dissatisfied with physical appearance
____worrying about a nervous breakdown ____feeling self critical or blaming yourself
____feeling out of control ____having negative thoughts
____avoiding being with people ____crying often
____fears of being alone or abandoned ____feeling empty
____feeling guilty ____withdrawing inside yourself
____having nightmares ____thinking too much about death
____flashbacks ____thoughts of hurting yourself
____troubling or painful memories ____thoughts of killing yourself
____missing periods of time - can't remember ____frequent mood swings
____trouble remembering things ____feeling resentful or angry
____feeling numb instead of upset ____feeling irritable or frustrated
____feeling detached from all or part of body ____feeling rage
____feeling unreal, strange or foggy ____feeling like hurting someone

__________________________________________________

Behavioral and Physical Concerns ____aggressive toward others

____not having an appetite ____impulsive reactions
____eating in binges ____trouble finishing things
____self induced vomiting for weight control ____working too hard
____using laxatives for weight control ____using alcohol too much
____eating too much ____being alcoholic
____eating too little ____using drugs
____losing weight - how much?_____ ____driving under the influence
____gaining weight - how much?____ ____blackouts - after drinking
____trouble sleeping
____trouble falling asleep ___Yes ___No Have you ever felt you ought to cut
____early morning awakening down on your drinking or drug use?
____sleeping too much ___Yes ___No Have people annoyed you by
____sleeping too little criticizing your drinking or drug use?
____# of hours I usually sleep: _____ ___Yes ___No Have you ever felt bad or guilty
____lack of exercise about your drinking or drug use?
____not having leisure activities ___Yes ___No Have you ever had a drink or used
____smoking cigarettes drugs first thing in the morning to
____often spending in binges steady your nerves or to get rid of a hangover?
____temper outbursts

_______________________________________________

Intimate Relationship Concerns ____lack of fairness in relationship

____feeling misunderstood in relationship ____problems with dividing household tasks
____not feeling close to partner ____disagreeing about children
____trouble communicating with partner ____lack of affection
____not trusting partner ____unsatisfactory sexual relationship
____lack of respect by partner ____lack of time together
____partner being secretive ____lack of shared interests
____lack of positive interaction
____lack of time with other couples ____partner having alcohol or drug problem
____jealousy in relationship ____self or partner having an affair
____frequent arguments ____feeling uncommitted to relationship
____trouble resolving conflict ____wanting to separate
____partner being demanding and controlling ____discussing separating or divorce
____partner putting you down ____problems with in-laws
____violent arguments ____problems with ex-partner
____emotional abuse in relationship ____problems with step parents
____physical abuse in relationship ____children having special problems
____sexual abuse in relationship

_________________________________________________

Sexual Concerns ____too anxious to have sex

____worrying about getting pregnant ____feeling a lack of sexual desire
____having miscarriage(s) ____wanting to have sex more often
____choice of birth control ____feeling neglected sexually
____having an abortion ____feeling used sexually
____not able to become pregnant ____feeling unable to have orgasm
____not enjoying sexual affection ____being unable to sustain an erection
____too tired to have sex ____feeling negatively about sex

_________________________________________________

When Growing Up to Present Time: ____close family member dying - who?

____being physically abused - by whom? ____felt neglected or unloved - by whom
____being emotionally abused - by whom? ____having an unhappy childhood
____being sexually abused - by whom? ____having serious medical problems - what?
____having an alcoholic parent - which? ____having drug or alcohol problem
____having a drug abusing parent - which? ____frequent moves
____having a depressed parent - which? ____having learning problems - what?
____having a parent with emotional problems ____having emotional problems
____having parents separate or divorce ____having attempted suicide - when?

___________________________________________________

Stresses During the Past Several Years: ____an important relationship ending - who?
____death of family member or friend - who? ____losing or changing job
____birth or adoption of child ____financial trouble
____self or family member hospitalized - who? ____legal problems
____moved ____natural disaster
____being harassed or assaulted ____serious or chronic illness -what:________
____frequent family or couple arguments ____________________________________________
____separation/divorce ____other

Please State Your Goals for Therapy:

1.______________________________________________________________________________________________

2.______________________________________________________________________________________________

3.______________________________________________________________________________________________

Additional Comments:

©Douglas Tilley, LCSW