Problem Checklist

Date:
Name:*

Please indicate the problems and concerns that you are currently or have recently been having. Circle the number indicating the seriousness of each identified problem area.

CODE PROBLEM(S) I HAVE: SERIOUSNESS OF PROBLEM(S) (Circle for applicable problems)
    No Problem A Small Problem A Moderate Problem A Serious Problem
2. Anxiety
5. Depression
9. Have Abused Others
16. Impulse Control Problems
7. Easy Loss of Temper
24. Mood Swings
14. Paranoia
25. Auditory Hallucinations (hear voices)
26. Visual Hallucinations (see odd things)
22. Racing Thoughts
18. Stress
19. Thoughts of Homicide
20. Thoughts of Suicide
1. Alcohol Abuse/Use
6. Drug Abuse/Use
4. Child Management
8. Family
27. Financial
88. Housing
11. Legal
12. Marital
13. Need for Medication
15. Physical Health/Chronic Pain
17. Relationship
3. Victim of Abuse
23. Other (Specify)