Marcia C. Barksdale, LPC-S

Islands Counseling      

Appointment: 228 324-5767     Counselor: 228 324-3244

www.islandscounseling.com


Adult Information Checklist



_______________________________________________________________________ Name:

The following are common concerns of individuals. Please check all that apply to you


 My family has a history of (check all that apply)

__ poor communication __ counseling __ abuse__ depression __ hospitalization __ alcoholism

__ eating disorders __ drug or gambling addiction

 I use alcohol

__ less than once per week __ more than once per week __ never

I use drugs

__ less than once per week __ more than once per week __ never

 The following have resulted from my use of alcohol/drugs (check all that apply)

__ traffic violation __ black outs __ financial problems__ ruined relationship 

__ health problems __ work or academic problems

 __ I have been in trouble with the legal system

 __ I have had an unwanted sexual experience

I have experienced (check all that apply)

__ emotional abuse __ sexual abuse __ physical abuse

I've tried to control my weight with (check all that apply)

__ vomiting __ laxatives __ not eating__ diet pills __ excessive exercise __ other

 I have thought or tried to (check all that apply)

__ harm myself __harm another person

__ At times, I have acted in a violent manner

 I have recently had problems with the following (check all that apply)

__ sleeping __ appetite __ fatigue__ concentration __ weight loss/gain __ mood shifts

__ headaches __ anxiety __ medical problems

I have difficulty (check all that apply)

__ expressing my emotions __ controlling my anger __handling stress

__ accepting myself __ accepting compliments

 I have experienced a recent (check all that apply)

__ death __ relationship that ended __ major move

 __ Sometimes I hear unwanted voices in my head


Information Checklist (Adult)


FOR EACH ISSUE, PLACE A CHECK UNDER THE NUMBER TO DECIDE HOW MUCH EACH

ISSUE HAS DISTRESSED, WORRIED, OR BOTHERED YOU IN THE PAST TWO WEEKS


1-Not at all 2-Slight 3-Moderate 4-Considerable 5-Extreme


Feeling angry 1 2 3 4 5

 Feeling timid or shy 1 2 3 4 5

 Feeling depressed 1 2 3 4 5

 Being easily embarrassed 1 2 3 4 5

 Feeling like a failure 1 2 3 4 5

 Feeling on the verge of tears 1 2 3 4 5

 Being ill at ease with others 1 2 3 4 5

 Feeling discouraged 1 2 3 4 5

 Not feeling like eating 1 2 3 4 5

 A lack of friends 1 2 3 4 5

 Feeling shy with the opposite sex 1 2 3 4 5

 Blame, criticize or condemn others 1 2 3 4 5

 Difficulty holding conversations 1 2 3 4 5

 Feeling hopeless 1 2 3 4 5

 Headaches 1 2 3 4 5

 Difficulty with Sleep 1 2 3 4 5

 Stay by yourself a lot 1 2 3 4 5

 Feeling tense and nervous 1 2 3 4 5

 Upset stomach 1 2 3 4 5

Sexual problems 1 2 3 4 5

 Suicidal thoughts 1 2 3 4 5

 Problems with family 1 2 3 4 5

 Upset by academic concerns 1 2 3 4 5

 Problems with spouse or significant other 1 2 3 4 5

 Stress related to work 1 2 3 4 5

 Stress related to school 1 2 3 4 5

 Being overweight 1 2 3 4 5

 Problems with anxiety 1 2 3 4 5

Unhappy with living arrangements 1 2 3 4 5


Please indicate how important spiritual and religious issues are in your life

_____________________________________________________________________________________


How much do spiritual and religious concerns affect your daily decision making

_____________________________________________________________________________________


List all persons living in the home including age and relationship to y

____________________________________________________________________________________


List all current medications you are taking including dosage, reason for taking the medication, and the

physician who prescribed the medication

_____________________________________________________________________________________


Have you been in therapy before?_________________________________________________________

How long?____________________________________________________________________________

With whom?___________________________________________________________________________


In order of importance, list the goals you have for counseling? Please be as specific as possible.

__________________________________________________________________________________  1

__________________________________________________________________________________ 2

__________________________________________________________________________________ 3



How many total sessions do you anticipate you will need to accomplish these goals                                      

1__ 2-4 __ 5-8 __ 9-12 __ 13-15 __ 16+__


Circle the number that best describes how much your concerns are interfering with your personal functioning.

(Not at all) 0 1 2 3 4 5 6 7 8 9 10 (A great deal)