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Name:   Address:   Phone:   Fax:   \nPRESENTING PROBLEM  \nWhat is the PROBLEM for which you are seeking assistance?    \n| When did you first notice this problem?   What caused you to seek treatment at this time?  |\n| --- |\n| How has this problem affected your ABILITY TO FUNCTION? At home:   |\n| At school/work:   |\n| In your community:   |\n\nWhat are SPECIFIC GOALS you want to accomplish by being in treatment? How do you want your life to be different?   \nSYMPTOM CHECKLISTS: Please indicate if you have experienced any of the following in the past two weeks. CIRCLE THE ITEM IF IT HAS BEEN LONG-STANDING OR SEEMS TO BE PART OF YOUR PERSONALITY.  \nDEPRESSION  \n☐ Sadness  \n☐ Hopeless/Discouraged  \n☐ Feelings of Failure  \n☐ Feeling Helpless  \n☐ Loss of Pleasure/Interest  \n☐ Feelings of Guilt ☐ Feeling Punished  \n☐ Loss of Confidence  \nBIPOLAR DISORDER  \n☐ Mood Swings ☐ Feeling “High” w/o drugs ☐ Elevated Self-Confidence ☐ More Outgoing/ Sociable ☐ Talking More or Faster ☐ Little Need for Sleep  \n☐ Self-criticism/Blame  \n☐ Hurting Yourself/Want to ☐ Suicidal Thoughts/wishes  \n☐ Crying  \n☐ Agitation / Restlessness  \n☐ Social Withdrawal  \n☐ Indecisiveness  \n☐ Feeling Worthless  \n☐ High Level of Energy  \n☐ Unusually Active  \n☐ Unusually Productive ☐ Can’t Focus on Tasks ☐ Racing Thoughts ☐ Can’t Shut Mind Off  \n☐ Loss of Energy/Fatigue  \n☐ Sleep Problems    \n☐ Irritability  \n☐ Appetite Change +/-  \n☐ Weight Gain/Loss   lbs.☐ Concentration Difficulty  \n☐ Poor Memory  \n☐ Loss of Interest in Sex  \n☐ Irritable/Argumentative  \n☐ Jumpy/Can’t Relax ☐ Excessive Spending  \n☐ Inapp. Sexual Behaviors  \n☐ Other Risky Behaviors  \nPOSTTRAUMATIC STRESS DISORDER  \n☐ Traumatic Memories  \n☐ Distressed at Reminders ☐ Easily Startled / Aroused  \nANXIETY  \n☐ Constant Worrying  \n☐ Fear of the Worst  \n☐ Scared/Terrified  \n☐ Feeling Hot/Face Flushed  \n☐ Sweating w/o Heat ☐ Wobbliness in Legs  \n☐ Unsteady  \n☐ Avoids Reminders  \n☐ Frequent Nightmares  \n☐ Flashbacks  \n☐ Hands Trembling  \n☐ Shaky  \n☐ Numbness/Tingling  \n☐ Nervous/Jittery  \n☐ Fear of Losing Control  \n☐ Fear of Going Crazy  \n☐ Fear of Dying  \n☐ Emotional Numbness  \n☐ Can’t Remember Event  \n☐ Unable to Relax ☐ Muscle Tension  \n☐ Dizzy/Lightheaded/Faint  \n☐ Heart Pounding/Racing  \n☐ Feelings of Choking ☐ Difficulty Breathing  \n☐ Abdominal Discomfort  \nSOCIAL ANXIETY  \n☐ Shy/Timid  \n☐ Avoiding Crowds  \n☐ Avoiding Public Places  \n☐ Self-conscious  \n☐ Dislike Attention on You ☐ Feeling Judged by Others  \nOBSESSIVE COMPULSIVE DISORDER  \n☐ Obsessive Thoughts ☐ Repetitive Thoughts  \n☐ Compulsive Hand Washing  \n☐ Compulsive Counting  \n☐ Compulsive “Checking”  \n☐ Compulsive Neatness  \nATTENTION/HYPERACTIVITY PROBLEMS  \n☐ Distractible  \n☐ Poor Concentration  \n☐ Many Unfinished Tasks  \n☐ Hyperactive  \nBEHAVIORAL PROBLEMS  \n☐ Physical Aggression ☐ Extreme Anger or Rage ☐ Verbal Altercations  \nEATING DISORDERS  \n☐ Fear of Weight Gain  \n☐ Binging/Purging  \n☐ Impulsive  \n☐ Procrastinates  \n☐ Forgetful  \n☐ Misplaces Things  \n☐ Destroying Property  \n☐ Throwing Things  \n☐ Distorted Body Image ☐ Excessive Exercising  \n☐ Indecisive  \n☐ Can’t Sit Still  \n☐ Leaves Seat  \n☐ Interrupts Others  \n☐ Fire Setting  \n☐ Hurting Animals  \n☐ Excessive Dieting  \n☐ Excessive Overeating  \nDISSOCIATION  \n☐ Feeling Outside Your Body ☐ Things Feel “Not Real”  \nPSYCHOSIS  \n☐ Hearing Voices Others Don’t ☐ Seeing Things Others Don’t  \nAUTISM SPECTRUM DISORDER  \n☐ Socially Unconnected/Awkward  \n☐ Avoids Eye Contact  \n☐ Language Impairments  \n☐ Time Elapsed, No Memory ☐ Gaps in Knowledge  \n☐ Paranoia  \n☐ Delusions  \n☐ Rigidity/Inflexibility  \n☐ Unusual Repetitive Behaviors ☐ Intense Preoccupation with Subject  \nMENTAL HEALTH HISTORY  \nHave you recently experienced a SIGNIFICANT LOSS?   If yes,","cbCaif9xA3CodIQm","https://ap.wps.com/l/cbCaif9xA3CodIQm","pdf",248878,10,"English","# Patient Information\n## Referral Information\n# Presenting Problem\n## Symptom Checklists\n# Mental Health History\n## Mental Health Diagnoses - Family History","[{\"question\":\"表单需要填写哪些患者基本信息？\",\"answer\":\"需要填写姓名、出生日期与年龄、性别和种族，以及住址和联系方式（电话、邮箱）。\"},{\"question\":\"“Presenting Problem”部分具体要回答什么？\",\"answer\":\"需填写正在寻求帮助的主要问题、首次察觉该问题的时间、当下寻求治疗的原因，以及该问题如何影响家庭、学业/工作与社区功能，同时说明希望通过治疗达到的具体目标与生活改变方向。\"},{\"question\":\"症状勾选清单涵盖哪些精神健康类别？\",\"answer\":\"包含抑郁、双相障碍、创伤后应激障碍、焦虑、社交焦虑、强迫症、注意力/多动问题、行为问题、进食障碍、分离症状、精神病性症状以及自闭谱系障碍等，并提示按过去两周经历情况进行勾选。\"}]","Adult Intake Form - Patient Information - Symptom Checklists | PDF",1789852199]