Adult Supplemental Information

Adult Supplemental Information
Name
Date of birth

MonthDayYear
Date
Please check any symptoms that apply:

Sad or unhappy most of the timeLow self worth/self esteemGuiltLoss of interest/not enjoying thingsDecreased energy/fatigueConcentration difficultiesSleep difficulties/Sleeping too muchThoughts of Suicide/self harmFeeling helpless/hopelessCrying spells/Cries easilyMoodiness/IrritabilityAnger/Angry outburstsFear of rejectionFeeling empty insideDecreased motivationRacing thoughtsAnxiety/worryPanic attacksFlashbacksNightmaresAvoid going places/being with othersChecking things repeatedlyObsessing/PerfectionisticFear of failure/disapprovalNeed to please or be likedDifficulty making decisionsDifficulty remembering/Losing itemsEasily distractedInattentivenessHyperactivityIncreased risk takingOverly talkativeLittle need for sleep/Excessive energyOn the go all the timeBody image difficultiesSexual difficultiesSexual addictionsExcessive alcohol useDrug useFeeling suspicious/paranoid at timesNot trusting othersHearing voices others don’t hearSeeing things others don’t seeLegal problemsWork problemsMarital/Relationship problemsFinancial problems/Excess spendingHealth 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 timePart timeUnemployedRetiredFull time studentPart 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

MarriedNever MarriedDivorcedCohabitatingLegally SeparatedWidowed
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)
Should be Empty: