SIDTC Questionnaire

Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Presenting Problem*
Ethnicity*

African AmericanCaucasianHispanicNative AmericanAsainOther
Have you been to therapy before?*

yesno
Are you currently taking any medications?*

YesNo
Please list all medications you are taking.
Do you have a history or are you currently using any substance (ie. illegal drugs, over using any prescription medications, over use of alcohol

YesNo
Highest level of education?
What is your religion?

ChristianCatholicBudistMuslimOther
Sexual Orientation

HeterosexualLesbianGayBisexualTransgenderedAsexualQueerOther
Gender Identity

MaleFemaleTransgendered womanTransgendered manNongender conformingOther
What are your preferred pronouns?

he/him/hisshe/her/hersThem/their/theirsOther
Do you have any allergies?

YesNo
What are you allergic to?
Have you ever been diagnosed with any mental disorder?

YesNo
What have you been diagnosed with?
Have you ever felt of experienced any of the following?
Type a question

Binging/PurgingIrritabiltyAnorexiaPanic AttacksOften destroy propertyAggresive BehaviorsFrequently aggressive towards animalsAgitationPhobiasOften set firesHave recurrent or persistant thoughts that bother youOften lose your temperExcessive anxiety/worry for over 6 months, more days than not.Difficulty controlling the worry, sleep disturbance, or restlessness.Re-experience in your mind bad things that have happened to youDepressed MoodHopelessnessMood SwingsSocial IsolationGriefPoor GroomingAppetite DisturbanceFeel depressed most of the day, nearly every day.Changes in sleepElavated MoodWithdrawnFeeling InadequateHave less interest/pleasure in doing things you usually enjoy doingFeel fatigued nearly every day.Feel worthless or excessively guilt most of the time.Have a difficult time thinking/concentrating, or feel indecisive a lotHave any beliefs that other people would think are strange.Ever wanted to hurt or kill yourself.Currently feel suicidal.Ever made, or currently have, a suicide plan.Ever attempted suicideDelusionsOften lose your temper?Often feel angry or resentful?Often argue with adults or authority figures?Often refuse to comply with rules?Often blame other people for your mistakesEver been diagnosed with ADHD?Often make careless mistakes?Often don’t finish assignments.Often distracted when listening to peopleHave trouble organizing tasks?Avoid things that take you a long time?Easily distracted by stuff going on around youOften forgetfulPoor MemoryOften fidgetOften feel restlessOften “on the go,” can’t sit still longOften talk too muchHave trouble waiting your turnOften blurt out the answers to questionsInterrupt a lotPhysical Trauma PerpetratorPhysical Trauma VictimSexual Trauma PerpetratorSexual Trauma VictimSexually Acting outSubstance AbuseSexual DysfunctionEmotional Trauma PerpetratorEmotional Trauma VictimSelf InjuryOther
Anything else we should know about you?
Family History
Who lives in your household?
Has your mother abused substances in the past/currently?

yesnoOther
Which substance?
Has your father abused substances in the past/currently?

yesnoOther
Which substance?
Has your sibling abused substances in the past/currently?

yesnoOther
Which substance?
Has your mother been diagnosed with a mental disorder in the past/currently?

yesnoOther
Which substance?
Has your father been diagnosed with a mental disorder in the past/currently?

yesnoOther
Which substance?
What are your goals for therapy?*
Should be Empty:

Have you ever felt of experienced any of the following?

Family History