Adult Supplemental Information

Name

Date of birth

Date

Please check any symptoms that apply:

Sad or unhappy most of the time Low self worth/self esteem Guilt Loss of interest/not enjoying things Decreased energy/fatigue Concentration difficulties Sleep difficulties/Sleeping too much Thoughts of Suicide/self harm Feeling helpless/hopeless Crying spells/Cries easily Moodiness/Irritability Anger/Angry outbursts Fear of rejection Feeling empty inside Decreased motivation Racing thoughts Anxiety/worry Panic attacks Flashbacks Nightmares Avoid going places/being with others Checking things repeatedly Obsessing/Perfectionistic Fear of failure/disapproval Need to please or be liked Difficulty making decisions Difficulty remembering/Losing items Easily distracted Inattentiveness Hyperactivity Increased risk taking Overly talkative Little need for sleep/Excessive energy On the go all the time Body image difficulties Sexual difficulties Sexual addictions Excessive alcohol use Drug use Feeling suspicious/paranoid at times Not trusting others Hearing voices others don’t hear Seeing things others don’t see Legal problems Work problems Marital/Relationship problems Financial problems/Excess spending Health problems/concerns

Are there other concerns (not listed above) you want to discuss?

How have these concerns impacted your daily life?

Education/Employment Information: Highest Grade Level Achieved and Area of Study

Employment status:

Full time Part time Unemployed Retired Full time student Part time student

Current/Most recent position and employer

How long with this job/company?

Any past/current military service? If yes, when/how long and what branch?

Family & Supportive Relationships

Marital Status

Married Never Married Divorced Cohabitating Legally Separated Widowed

Please list your family members and close relationships in the typing fields below. List the following information:

Name

Age

Relationship (eg: father, daughter)

Relationship Quality (eg:Poor, Fair, Good, Close, Distant)

Living with you? (Y/N)

Relationship #1- Name, Age, Relationship, Relationship Quality, Living With You (Y/N)

Relationship #2- Name, Age, Relationship, Relationship Quality, Living With You (Y/N)

Relationship #3- Name, Age, Relationship, Relationship Quality, Living With You (Y/N)

Relationship #4- Name, Age, Relationship, Relationship Quality, Living With You (Y/N)

Relationship #5- Name, Age, Relationship, Relationship Quality, Living With You (Y/N)

Relationship #6- Name, Age, Relationship, Relationship Quality, Living With You (Y/N)