Screening Tool

Symptom Assessment

Please give us a brief history and symptom overview so we can ensure that you receive the most appropriate assessment and services for your needs. If you have any questions, please don’t hesitate to let us know so we can better service you.


I AM EXPERIENCING…	NEVER	SELDOM	OFTEN	ALWAYS	FOR HOW LONG?
Frequent worry or tension	never	seldom	often	always
Fear of many things	never	seldom	often	always
Discomfort in social situations	never	seldom	often	always
Feelings of guilt	never	seldom	often	always
Phobias: unusual fears of specific things	never	seldom	often	always
Panic Attacks: Shortness of breath, sweating, trembling, heart palpitations	never	seldom	often	always
Recurring, distressing thoughts about trauma	never	seldom	often	always
“Flashbacks” as if reliving trauma	never	seldom	often	always
Avoiding people/places associated with trauma	never	seldom	often	always
Nightmares about traumatic event	never	seldom	often	always
I AM FEELING…	NEVER	SELDOM	OFTEN	ALWAYS	FOR HOW LONG?
Decreased interest in pleasurable activities	never	seldom	often	always
Social Isolation/ Withdrawal	never	seldom	often	always
Suicidal Thoughts	never	seldom	often	always
Feelings of loss	never	seldom	often	always
Changes in sleep (too much, too little)	never	seldom	often	always
Normal, daily tasks require extra energy	never	seldom	often	always
Sad, hopeless about future	never	seldom	often	always
Excessive feelings about guilt	never	seldom	often	always
Low self-esteem	never	seldom	often	always
I NOTICE/OTHERS HAVE NOTICED…	NEVER	SELDOM	OFTEN	ALWAYS	FOR HOW LONG?
I am angry, hostile or irritable	never	seldom	often	always
I feel euphoric, energized, highly optimistic	never	seldom	often	always
I have racing thoughts	never	seldom	often	always
I require less sleep than normal	never	seldom	often	always
I am more talkative	never	seldom	often	always
My moods go up and down	never	seldom	often	always
I HAVE…	NEVER	SELDOM	OFTEN	ALWAYS	FOR HOW LONG?
Memory problems or trouble concentrating	never	seldom	often	always
Trouble explaining myself to others	never	seldom	often	always
Problems understanding what others tell me	never	seldom	often	always
Intrusive or strange thoughts	never	seldom	often	always
Obsessive thoughts	never	seldom	often	always
Hear voices or sounds when I’m alone	never	seldom	often	always
I ENGAGE IN…	NEVER	SELDOM	OFTEN	ALWAYS	FOR HOW LONG?
Risk taking behaviors	never	seldom	often	always
Compulsive or repetitive behaviors	never	seldom	often	always
Engage in activities without concern of consequences	never	seldom	often	always
Been physically harming myself	never	seldom	often	always
Been violent towards others	never	seldom	often	always
I USE THE FOLLOWING…	NEVER	SELDOM	OFTEN	ALWAYS	FOR HOW LONG?
Alcohol	never	seldom	often	always
Tobacco or Nicotine	never	seldom	often	always
Marijuana	never	seldom	often	always
Cocaine	never	seldom	often	always
Opiate Medication	never	seldom	often	always
Sedatives	never	seldom	often	always
Hallucinogens	never	seldom	often	always
Stimulants	never	seldom	often	always
Methamphetamine	never	seldom	often	always
Heroin	never	seldom	often	always
MY EATING INVOLVES…	NEVER	SELDOM	OFTEN	ALWAYS	FOR HOW LONG?
Restriction of food consumption	never	seldom	often	always
Binging and purging	never	seldom	often	always
Binge eating	never	seldom	often	always
Excessive weight gain or loss	never	seldom	often	always

Personal and Family History

Have you even been diagnosed with a mental illness? No NO Yes YES: (Please Explain)

When: Diagnosis:

Have you ever received mental health services in the past? No NO Yes YES: (Please Explain)

When: Where:

Type of Services:

Have you ever been hospitalized for any psychiatric reasons? No NO Yes YES: (Please Explain)

When: When:

How Long: How Long:

Location: Location:

Does anyone in your family have a history of mental illness? No NO Yes YES: (Please Explain)

Relationship: Diagnosis:

Have you ever received substance abuse treatment in the past? No NO Yes YES: (Please Explain)

When: Where:

Inpatient: Outpatient:

Court Mandated: Voluntarily:

What is the primary reason you are seeking services?

What type of services are you interested in receiving?

Medication Management/Psychiatric Individual Therapy Group Therapy

Family Therapy Intensive Outpatient Services Rehabilitation (PSR/BST)

Individual Substance Abuse Therapy Substance Abuse Group Other:

Do you need Transportation? No NO Yes YES: (Please Explain)

What Are The Benefits of Group Therapy?
September 7, 2016