CHECK LIST OF CONCERNS
NAME________________________________________________
Please mark all of the items below that apply. In addition, please feel free to list any other concerns you may have that are not listed.
__Abuse – physical, mental, sexual, emotional
__Aggression, violence
__Alcohol use
__Anger, hostility, arguing, irritability
__Anxiety, nervousness
__Attention deficit, concentration, distractibility
__Career concerns
__Codependence
__Confusion
__Compulsions, obessions
__Custody of children
__Decision making, indecision, putting off decisions
__Delusions (false beliefs)
__Dependence
__Depression, low mood, sadness, crying
__Divorce, separation
__Drug use-prescription medications, street drugs
__Eating problems, overeating, undereating, forced vomiting
__Emptiness
__Failure – fear of failure
__Fatigue, tiredness, low energy
__Fears, phobias
__Financial or money problems, debt, impulsive spending
__Friendships – lack of friendships
__Gambling
__Grieving, mourning, deaths, losses, divorce
__Guilt
__Headaches, other pains
__Health, illness, medical concerns, physical problems
__Inferiority feelings
__Interpersonal conflicts
__Impulsiveness, loss of control, outbursts
__Irresponsibility
__Judgement problems, risk taking
__Legal matters, charges pending, suits
__Loneliness
__Marriage conflict, distance/coldness, infidelity, remarriage
__Memory problems
__Menstrual problems, PMS, PMDD, menopause
__Mood swings
__Motivation, laziness
__Nervousness, tension
__Obsessions, compulsions, thoughts or actions that repeat themselves
__Oversensitivity, Feelings easily hurt
__Pain, chronic
__Panic or anxiety attacks
__Parenting issues, single parenting
__Perfectionism
__Pessimism
__Procrastination
__Relationship problems with family, friends, co-workers
__School problems (see also career concerns)
__Self-centeredness
__Self-esteem
__Self neglect, poor self -care
__Sexual issues, dysfunctions
__Shyness, oversensitivity to criticism
__Sleep problems, too much, too little, nightmares, insomnia
__Smoking and tabaco use
__Spiritual, religious, moral, ethical issues
__Stress, inability to relax, tension
__Suspiciousness, distrust, jealousy issues
__Suicidal thoughts
__Temper problems, inability to control
__Thought disorganization, confusion
__Weight and diet issues
__Other concerns
