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Step
1
of
8
12%
Name
*
First
Last
I AM EXPERIENCING...
Frequent worry or tension
*
Never
Sometimes
Often
Always
For how long?
Fear of many things
*
Never
Sometimes
Often
Always
For how long?
Discomfort in social situations
*
Never
Sometimes
Often
Always
For how long?
Feelings of guilt
*
Never
Sometimes
Often
Always
For how long?
Phobias: unusual fears about specific things
*
Never
Sometimes
Often
Always
For how long?
Panic Attacks: Sweating, trembling, shortness of breath, heart palpitations
*
Never
Sometimes
Often
Always
For how long?
Recurring, distressing thoughts about a trauma
*
Never
Sometimes
Often
Always
For how long?
“Flashbacks” as if reliving the traumatic event
*
Never
Sometimes
Often
Always
For how long?
Avoiding people/places associated with trauma
*
Never
Sometimes
Often
Always
For how long?
Nightmares about traumatic experience
*
Never
Sometimes
Often
Always
For how long?
I AM FEELING...
Decreased interest in pleasurable activities
*
Never
Sometimes
Often
Always
For how long?
For how long?
Suicidal Thoughts
*
Never
Sometimes
Often
Always
For how long?
Bereavement or Feelings of Loss
*
Never
Sometimes
Often
Always
For how long?
Changes in sleep (too much or not enough)
*
Never
Sometimes
Often
Always
For how long?
Normal, daily tasks require more effort
*
Never
Sometimes
Often
Always
For how long?
Sad, hopeless about future
*
Never
Sometimes
Often
Always
For how long?
Excessive feelings of guilt
*
Never
Sometimes
Often
Always
For how long?
Low self-esteem
*
Never
Sometimes
Often
Always
For how long?
I NOTICE...
I am Angry, Irritable, hostile
*
Never
Sometimes
Often
Always
For how long?
I feel euphoric, energized and highly optimistic
*
Never
Sometimes
Often
Always
For how long?
I have racing thoughts
*
Never
Sometimes
Often
Always
For how long?
I need less sleep than usual
*
Never
Sometimes
Often
Always
For how long?
I am more talkative
*
Never
Sometimes
Often
Always
For how long?
My moods fluctuate: go up and down
*
Never
Sometimes
Often
Always
For how long?
I HAVE...
Memory problems or trouble concentrating
*
Never
Sometimes
Often
Always
For how long?
Trouble explaining myself to others
*
Never
Sometimes
Often
Always
For how long?
Problems understanding what others tell me
*
Never
Sometimes
Often
Always
For how long?
Intrusive or strange thoughts
*
Never
Sometimes
Often
Always
For how long?
Obsessive Thoughts
*
Never
Sometimes
Often
Always
For how long?
Been hearing voices when alone
*
Never
Sometimes
Often
Always
For how long?
Problems with my speech
*
Never
Sometimes
Often
Always
For how long?
Risk Taking behaviors
*
Never
Sometimes
Often
Always
For how long?
Compulsive or repetitive behaviors
*
Never
Sometimes
Often
Always
For how long?
Been acting without concern for consequence
*
Never
Sometimes
Often
Always
For how long?
Been physically harming myself
*
Never
Sometimes
Often
Always
For how long?
Been violent toward other(s)
*
Never
Sometimes
Often
Always
For how long?
Thoughts about harming my children
*
Never
Sometimes
Often
Always
For how long?
Concern about my sexual function
*
Never
Sometimes
Often
Always
For how long?
Discomfort engaging in sexual activity
*
Never
Sometimes
Often
Always
For how long?
Questions about my sexual orientation
*
Never
Sometimes
Often
Always
For how long?
Questions about my gender expression
*
Never
Sometimes
Often
Always
For how long?
Concern for my safety at home
*
Never
Sometimes
Often
Always
For how long?
Concern for my safety outside
*
Never
Sometimes
Often
Always
For how long?
MY EATING INVOLVES…
Restriction of food consumption
*
Never
Sometimes
Often
Always
For how long?
Bingeing and Purging
*
Never
Sometimes
Often
Always
For how long?
Binge Eating
*
Never
Sometimes
Often
Always
For how long?
A lot of weight loss or gain
*
Never
Sometimes
Often
Always
For how long?
I USE THE FOLLOWING....
Alcohol
*
Never
Sometimes
Often
Always
For how long?
Nicotine (Cigarettes / Vaping)
*
Never
Sometimes
Often
Always
For how long?
Marijuana
*
Never
Sometimes
Often
Always
For how long?
Cocaine
*
Never
Sometimes
Often
Always
For how long?
Opiates
*
Never
Sometimes
Often
Always
For how long?
Sedatives
*
Never
Sometimes
Often
Always
For how long?
Hallucinogens
*
Never
Sometimes
Often
Always
For how long?
Stimulants
*
Never
Sometimes
Often
Always
For how long?
Methamphetamines
*
Never
Sometimes
Often
Always
For how long?
Prescription pain pills
*
Never
Sometimes
Often
Always
For how long?
Synthetic drugs (ecstasy, etc.)
*
Never
Sometimes
Often
Always
For how long?
EMPLOYMENT & SELF-CARE...
I have problems getting/keeping a job
*
Never
Sometimes
Often
Always
For how long?
I have problems paying for basic expenses
*
Never
Sometimes
Often
Always
For how long?
I am afraid of becoming homeless
*
Never
Sometimes
Often
Always
For how long?
I have problems accessing healthcare
*
Never
Sometimes
Often
Always
For how long?
I don’t have reliable transportation
*
Never
Sometimes
Often
Always
For how long?
Are there any other concerns that you’d like us to help with not indicated above?
Consent
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