Problem Checklist

Name: _____________________________________ Date:_________________

Individual Problem Checklist

Directions:

Put a number next to any item which you experience.

1=mildly, 2=moderately, 3=severely

Emotional Concerns

__________________________________________________

Behavioral and Physical Concerns

_______________________________________________

Intimate Relationship Concerns

_________________________________________________

Sexual Concerns

_________________________________________________

When Growing Up to Present Time:

___________________________________________________

Stresses During the Past Several Years:

Please State Your Goals for Therapy

1.______________________________________________________________________________________________

2.______________________________________________________________________________________________

3.______________________________________________________________________________________________

Additional Comments:

©Douglas Tilley, LCSW :

____death of family member or friend - who?

____birth or adoption of child

____self or family member hospitalized - who?

____moved

____being harassed or assaulted

____frequent family or couple arguments

____separation/divorce

____an important relationship ending - who?

____losing or changing job

____financial trouble

____legal problems

____natural disaster

____serious or chronic illness -what:________

____________________________________________

____other

____being physically abused - by whom?

____being emotionally abused - by whom?

____being sexually abused - by whom?

____having an alcoholic parent - which?

____having a drug abusing parent - which?

____having a depressed parent - which?

____having a parent with emotional problems

____having parents separate or divorce

____close family member dying - who?

____felt neglected or unloved - by whom

____having an unhappy childhood

____having serious medical problems - what?

____having drug or alcohol problem

____frequent moves

____having learning problems - what?

____having emotional problems

____having attempted suicide - when?

____worrying about getting pregnant

____having miscarriage(s)

____choice of birth control

____having an abortion

____not able to become pregnant

____not enjoying sexual affection

____too tired to have sex

____too anxious to have sex

____feeling a lack of sexual desire

____wanting to have sex more often

____feeling neglected sexually

____feeling used sexually

____feeling unable to have orgasm

____being unable to sustain an erection

____feeling negatively about sex

____feeling misunderstood in relationship

____not feeling close to partner

____trouble communicating with partner

____not trusting partner

____lack of respect by partner

____partner being secretive

____lack of fairness in relationship

____problems with dividing household tasks

____disagreeing about children

____lack of affection

____unsatisfactory sexual relationship

____lack of time together

____lack of shared interests

____lack of positive interaction

____lack of time with other couples

____jealousy in relationship

____frequent arguments

____trouble resolving conflict

____partner being demanding and controlling

____partner putting you down

____violent arguments

____emotional abuse in relationship

____physical abuse in relationship

____sexual abuse in relationship

____partner having alcohol or drug problem

____self or partner having an affair

____feeling uncommitted to relationship

____wanting to separate

____discussing separating or divorce

____problems with in-laws

____problems with ex-partner

____problems with step parents

____children having special problems

____not having an appetite

____eating in binges

____self induced vomiting for weight control

____using laxatives for weight control

____eating too much

____eating too little

____losing weight - how much?_____

____gaining weight - how much?____

____trouble sleeping

____trouble falling asleep

____early morning awakening

____sleeping too much

____sleeping too little

____# of hours I usually sleep: _____

____lack of exercise

____not having leisure activities

____smoking cigarettes

____often spending in binges

____temper outbursts

____aggressive toward others

____impulsive reactions

____trouble finishing things

____working too hard

____using alcohol too much

____being alcoholic

____using drugs

____driving under the influence

____blackouts - after drinking

___Yes ___No Have you ever felt you ought to cut down on your drinking or drug use?

___Yes ___No Have people annoyed you by criticizing your drinking or drug use?

___Yes ___No Have you ever felt bad or guilty about your drinking or drug use?

___Yes ___No Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

____feeling anxious or uptight

____excessive worrying

____not being able to relax

____feeling panicky

____unable to calm yourself down

____dwelling on certain thoughts or images

____fearing something terrible about to happen

____avoiding certain thoughts or feelings

____having strong fears

____worrying about a nervous breakdown

____feeling out of control

____avoiding being with people

____fears of being alone or abandoned

____feeling guilty

____having nightmares

____flashbacks

____troubling or painful memories

____missing periods of time - can't remember

____trouble remembering things

____feeling numb instead of upset

____feeling detached from all or part of body

____feeling unreal, strange or foggy

____feeling depressed or sad

____being tired or lacking energy

____feeling unmotivated

____loss of interest in many things

____having trouble concentrating

____having trouble making decisions

____feeling the future looks hopeless

____feeling worthless or a failure

____being unhappy all the time

____dissatisfied with physical appearance

____feeling self critical or blaming yourself

____having negative thoughts

____crying often

____feeling empty

____withdrawing inside yourself

____thinking too much about death

____thoughts of hurting yourself

____thoughts of killing yourself

____frequent mood swings

____feeling resentful or angry

____feeling irritable or frustrated

____feeling rage

____feeling like hurting someone