Adolescent Supplemental Information

Adolescent Supplemental Information
Your Name
Date of birth

MonthDayYear
Date
Why did you come today?
Whose idea was it that you come?
Please check those that apply to you, section 1.

I'm sad or unhappy most of the timeLow self-worth/self esteemI have nothing to look forward toI don't care about much anymoreI don't enjoy things I used toI'm tired or out of energyLife is unfairI'm not sleeping/sleeping too muchI've thought about suicideI've hurt myself (cut, burned, etc)I feel helpless or hopelessI cry a lot/easilyI'm afraid a lotI'm often angry or irritableI'm afraid of being rejectedI'm too shyMy mind races a lotI worry a lotI don't like going new placesI've had times I felt panickedI have flashbacks/nightmaresI have a hard time making decisionsI check things over and overI'm not confident in myself
Please check those that apply to you, section 2.

I'm afraid of failingI often daydream or get distractedI forget thingsI'm easily boredI don't finish things I startI prefer being active over sitting stillI lose thing easilyI do things without thinkingI need a lot of remindersI like/demand attention from othersI love to take risksI talk too muchI don't need much sleepI feel "on the go" a lotI don't like my appearanceI have a lot of aches/painMy weight has changed a lotI've been a victim of sexual abuseI've stolen/shoplifted in the pastI have concerns about sex/sexualityI look at pornographyI've consumed alcoholI've tried marijuana/other drugsMy friends use alcohol/drugs
Please check those that apply to you, section 3.

I don't trust others easilyI see/hear things others do notI get in trouble for talking backI get in trouble at school sometimesI have conflict with my teachersI break rules at homeI've been in trouble with the policeI've thought about running awayI have arguments with friendsI wish I had more friendsClassmates are mean to meMy classmates think I'm weirdI prefer to just be alonePeople say I'm bossyI'm sensitive to being criticizedI tell more lies than I shouldI swear more than I shouldIt's hard to follow instructionsI am disappointed with my gradesOthers are disappointed with my gradesHomework is difficult for meI hate going to/have skipped schoolWhen I take a test, I can't think
Are there other concerns (not listed above) you want to discuss?
What are some things you are good at? (Strengths? Favorite things? Etc?)
What are some things you're not very good at? (Weaknesses? Least favorite things?)
Do you have at least one friend who you really like and feel you can talk to?

YesNoNot sure
Do you think that your parents listen to you and take your feelings seriously?

YesNoNot sure
Have you had fun in the last two weeks?

YesNo
If you had fun in the last two weeks, what were you doing?
What words would you use to describe yourself?
If you could change one thing about your life or yourself, what would it be?
What do you like about school?
What do you dislike about school?
How do you feel about your teachers?
What extracurricular activities are you involved in ?
Should be Empty: