Client Sympton Checklist

Full Name

Phone

Email

Complains of aches/pains

Never (0)

Sometimes (1)

Often (2)

Spends more time alone

Never (0)

Sometimes (1)

Often (2)

Tires easily, has little energy

Never (0)

Sometimes (1)

Often (2)

Fidgety, unable to sit still

Never (1)

Sometimes (1)

Often (2)

Has trouble with authority/demands

Never (0)

Sometimes (1)

Often (2)

Less interested in responsibilities

Never (0)

Sometimes (1)

Often (2)

Acts as if driven by a motor

Never (0)

Sometimes (1)

Often (2)

Is irritable, angry

Never (0)

Sometimes (1)

Often (2)

Daydreams too much

Never (0)

Sometimes (1)

Never (2)

Distracted easily

Never (0)

Sometimes (1)

Often (2)

Feels hopeless

Never (0)

Sometimes (1)

Often (2)

Is afraid of new situations

Never (0)

Sometimes (1)

Often (2)

Has trouble concentrating

Never (0)

Sometimes (1)

Often (2)

Fights/ argues with others

Never (0)

Sometimes (1)

Often (2)

Absent from school/ work

Never (0)

Sometimes (1)

Often (2)

School grades dropping (kid)

Never (0)

Sometimes (1)

Often (2)

Is down on him or herself

Never (0)

Sometimes (1)

Often (2)

Visits doctor but finds nothing wrong

Never (0)

Sometimes (1)

Often (2)

Has trouble sleeping

Never (0)

Sometimes (1)

Often (2)

Worries a lot

Never (0)

Sometimes (1)

Often (2)

Gets hurt frequently

Never (0)

Sometimes (1)

Often (2)

Seems to be very clingy

Never (0)

Sometimes (1)

Often (2)

Feels he or she is bad

Never (0)

Sometimes (1)

Often (2)

Seems to be having less fun

Never (0)

Sometimes (1)

Often 2)

Takes unnecessary risks

Never (0)

Sometimes (1)

Often (2)

Does not listen to rules

Never (0)

Sometimes (1)

Often (2)

Does not show feelings

Never (0)

Sometimes (1)

Often (2)

Acts younger than their age

Never (0)

Sometimes (1)

Often 2)

Refuses to share

Never (0)

Sometimes (1)

Often (2)

Teases others

Never (0)

Sometimes (1)

Often (2)

Does not understand other people

Never (0)

Sometimes (1)

Often (2)

Takes things that don't belong to them

Never (0)

Sometimes (1)

Often (2)

Blames others for their troubles

Never (0)

Sometimes (1)

Often (2)

Do you have any emotional or behavioral problems for which counseling is needed?

Yes

No

Are there any services that you would like to receive for these problems?

Yes

No

If yes what services

Counseling and Therapy for individuals, couples and families.

Counseling and Therapy for individuals, children and couples.

Contact Us

Change starts with a single step forwards

All Referrals