Adolescent Supplemental Information

Adolescent Supplemental Information
Your Name
Date of birth

Month Day Year
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 time Low self-worth/self esteem I have nothing to look forward to I don't care about much anymore I don't enjoy things I used to I'm tired or out of energy Life is unfair I'm not sleeping/sleeping too much I've thought about suicide I've hurt myself (cut, burned, etc) I feel helpless or hopeless I cry a lot/easily I'm afraid a lot I'm often angry or irritable I'm afraid of being rejected I'm too shy My mind races a lot I worry a lot I don't like going new places I've had times I felt panicked I have flashbacks/nightmares I have a hard time making decisions I check things over and over I'm not confident in myself
Please check those that apply to you, section 2.

I'm afraid of failing I often daydream or get distracted I forget things I'm easily bored I don't finish things I start I prefer being active over sitting still I lose thing easily I do things without thinking I need a lot of reminders I like/demand attention from others I love to take risks I talk too much I don't need much sleep I feel "on the go" a lot I don't like my appearance I have a lot of aches/pain My weight has changed a lot I've been a victim of sexual abuse I've stolen/shoplifted in the past I have concerns about sex/sexuality I look at pornography I've consumed alcohol I've tried marijuana/other drugs My friends use alcohol/drugs
Please check those that apply to you, section 3.

I don't trust others easily I see/hear things others do not I get in trouble for talking back I get in trouble at school sometimes I have conflict with my teachers I break rules at home I've been in trouble with the police I've thought about running away I have arguments with friends I wish I had more friends Classmates are mean to me My classmates think I'm weird I prefer to just be alone People say I'm bossy I'm sensitive to being criticized I tell more lies than I should I swear more than I should It's hard to follow instructions I am disappointed with my grades Others are disappointed with my grades Homework is difficult for me I hate going to/have skipped school When 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?

Yes No Not sure
Do you think that your parents listen to you and take your feelings seriously?

Yes No Not sure
Have you had fun in the last two weeks?

Yes No
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: