Teen and Young Adult Clinical Questionnaire

AUBREY K. EWING PH.D. & ASSOCIATES, P.A. 1230 So. Federal Hwy, Boynton Beach, FL 33435

TEEN & YOUNG ADULT CLINICAL QUESTIONNAIRE

Please answer all of the questions on the following pages as honestly and accurately as you can. Your answers to these questions are private and no one will see them but your counselor (not even parents unless you give permission The information you provide gives us a head-start in understanding how we can be of help.
Your name
Email address we can use to let you know we received this questionnaire
example@example.com
Date of birth

MonthDayYear
Date
Age
Gender
Grade/year in school
Name of your school
Are you involved in after school or extracurricular activities (sports, karate, dance, etc.)?
If yes, what are your activities?
Do you have a job?
If yes, where do you work?
Parents' (or guardians') names
Briefly describe your everyday life (like where you live, who you live with, if you have any pets, who are the important people in your life, what it's like living in your home, and anything else you want share).
Name all of the people living in your house, their ages, and their relationships to you:
Example: "Jason, brother, age 10; Rick, dad, age 42..."
Whose idea was it for you to come to counseling?
What is the reason for your counseling appointment?
If it was someone else's idea for you to come for counseling, why do you think they wanted you to come?
If you are having bad feelings or thoughts, please describe them in your own words.
What are you most worried might happen if things don't change?
Have you ever had similar thoughts, feelings, or problems before now? If yes, please describe them, when they occurred, and if anything was done about them.
Have you ever seen another professional (counselor, therapist, psychologist, or psychiatrist) for emotional, behavioral, or learning problems?
If yes, do you think it helped?
Have you ever taken medication to help with emotional, behavioral, or learning problems?
If yes, when?
If you are taking medication now and you know what it is, please list the medicines you take. If you don’t know, you can skip this part.
Do you have any medical or physical problems that are currently bothering you or for which you see a doctor. If so, describe them in your own words.
HISTORY OF IMPORTANT LIFE EVENTS AND PROBLEMS
Please place a check in front of all the statements below that apply to you:

I had to repeat a grade in schoolI have been in at least one special education classI have been in advanced classes for smart kidsI have been in gifted or AP classes?
Do any of the following statements describe you (check all that fit):

I often leave things unfinishedI am easily distracted or have trouble paying attentionI have difficulty concentrating on reading or homeworkI have difficulty sitting stillI feel restless, fidgety, like I need to moveI sometimes act without thinking about what I'm doing or what the consequences might beI often misplace or lose thingsI forget things easily and need to be reminded a lot
Check the statements below that best describe you and the things you’ve done (check all that apply):

I am unusually stubborn and want things my wayI have trouble following rulesI often do the opposite of what people tell me to doI argue with my parents and teachersI tend to lose my temper easily, and sometimes throw or break thingsI have shoplifted or stolen somethingI have skipped school without permissionI have run away from home overnightI often tell lies to my parents or teachersI have snuck out of the house at nightI have set fires that could have been dangerousI have injured or killed a pet or small animal just for amusementI have purposely broken or damaged someone else’s propertyI have a reputation for starting fightsI have displayed a knife, gun, or other weapon in a threatening way toward someoneI have tried to steal things by threatening someoneI have tried to force another person to engage in a sexual act
Check the ones below that apply to you:

I smoke cigarettes regularlyI have drunk beer, wine, or other alcoholic beverages, recently or in the pastI have missed school or my job (or was asked to leave) because of drinkingI have sniffed fumes (whippets, poppers, glue, gasoline, other inhalants) to get highI have smoked weed (marijuana)I have used amphetamines (crystal meth, Molly, ice, speed)I have used cocaine (coke, crack, rocks)I have used hallucinogens (LSD, PCP, peyote, mescaline)?I have used heroin, opiates (H, junk, mud, horse, fentanyl)?I have abused prescription medication (roxys, blues, pain/sleep, ADD meds)I have abused other medicines like DXMI have abused sedatives, tranquilizers (downers, bars, Xanax)I am regularly using some of the above substances now
Have you recently or in the past had a period of time that lasted two weeks or longer when you:

seemed to be sad, depressed, in a bad mood?felt like you could cry or get upset more easily than usual?felt more irritable or got angry more easily?didn’t feel much like eating or lost weight?felt like eating more than usual or gained extra weight?had trouble falling asleep or staying asleep?slept more than usual or had trouble waking up?didn’t feel like being around family and friends; talked less than usual?lost interest in things you usually like to do?had less energy or motivation than you usually do?felt tired a lot of the time but weren’t physically sick?felt achy a lot of the time headaches, stomachaches, etc?felt guilty over things you really weren’t to blame for?felt worthless and thought you would be better off dead?couldn’t concentrate as well on school or work?talked about you or some one else dying?thought a lot about death or dying?I am feeling sad, blue, moody, or irritable now (check if yes).I have experienced at least five of the items I checked above continuously for the past two weeks or longer (check if yes).
Have you ever had a period of time lasting at least one week when you:

were so overly happy or “high” (not on drugs) that you got into trouble?became more hyper than usual so much so that it made others worry about you?talked faster or more constantly than usual?felt your thoughts were going very fast (racing) in your head?felt you had special powers to do amazing things?slept a lot less than usual and didn’t feel overly tired?weren’t able to concentrate on things as well as usual?did outrageous, over the top things you later regretted (like acting wild, spending money, taking risks, sex)?
Please check the statements below that describe you most of the time:

I am an anxious (nervous) personI tend to worry a lotI sometimes think too much about my health or worry a lot about being sickI worry about being away from my parentsI feel very uncomfortable (nervous) around people unless I know them wellI sometimes have headaches or stomach aches before schoolI worry that something will happen to me or my parentsI need to have a parent close to me to fall asleepI have had an attack of severe nervousness or anxiety for no apparent reason. If yes, how often have you experienced these attacks?
During an anxiety attack I (check all that apply—skip if you don’t have anxiety attacks):

have trouble catching my breathmy heart races too fastmy face becomes red or flushed or my hands begin to sweatfeel afraid but don’t know why?am scared I will faint or lose control?
Please check all that are true about you:

I have had unusual, troublesome (scary) thoughts that I can’t put out of my mind (like getting hurt, infected by germs, about bugs/insects, etc.)I have special habits or rituals that I have to do that seem excessive or unnecessary (counting things, touching, hand washing, etc)Certain numbers or sequences have special meaning to meI check and recheck way too much on things I’ve already done, like turningI tend to get highly upset when things are not in their exact place
Please check any below that apply to you:

I am overly preoccupied with thoughts about my weightI think I am too fatI have lost a lot of weight on purposeI exercise in order to lose weightI go on eating binges where I eat way too much at onceI have made myself throw up after regular meals or after binging on foodI have tried diet pills or laxatives to lose weight
I have sudden, jerky movements, which are repetitive, like neck jerks, eye blinking, mouth twitches, shoulder shrugsI have a habit (now or in the past) of making repetitive sounds such as sniffs, grunts, throat clearing, barking, etc.I currently or used to have a habit of rocking my body or moving my fingers and hands in a repetitive way?
Sometimes I have had strange thoughts or experiences that I didn’t understand, such as (check the boxes that apply):

thinking someone was out to get methinking that others could control my thoughtsbelieving that someone on TV or other media was talking about mehearing voices in my head others could not hear that seemed real, and were telling me strange thingsseeing things, having visions that others don’t see
Check the box in front of each statement below that describes you:

I don’t seem to like affection such as hugs, kisses, or sitting close to peopleI am sort of uninterested in or feel weird around other kids my agePeople seem to think I use unusual or peculiar language with othersI still wet the bed or have daytime urinary or bowel accidentsI think I am more interested in things (or video/computer games) than in peoplesometimes have repeated movements that I can’t control, like flapping my hands or arms, clapping, twirling, etcI get very upset with even small changes to my routine or when things are out of placeI have habits of hurting myself (cutting, biting, hitting, hair pulling)
If there is anything else you want to tell about yourself, your feelings, or about important things happening in your life, please write anything you want in the space below.
Thank you for taking the time to answer these important questions. The information you provided is helpful to your counselor in getting to know you and how to best help you and your family.
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