SIDTC Questionnaire

Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Presenting Problem *
Ethnicity *

African American Caucasian Hispanic Native American Asain
Have you been to therapy before? *

yes no
Are you currently taking any medications? *

Yes No
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

Yes No
Highest level of education?
What is your religion?

Christian Catholic Budist Muslim
Sexual Orientation

Heterosexual Lesbian Gay Bisexual Transgendered Asexual Queer
Gender Identity

Male Female Transgendered woman Transgendered man Nongender conforming
What are your preferred pronouns?

he/him/his she/her/hers Them/their/theirs
Do you have any allergies?

Yes No
What are you allergic to?
Have you ever been diagnosed with any mental disorder?

Yes No
What have you been diagnosed with?
Have you ever felt of experienced any of the following?
Type a question

Binging/Purging Irritabilty Anorexia Panic Attacks Often destroy property Aggresive Behaviors Frequently aggressive towards animals Agitation Phobias Often set fires Have recurrent or persistant thoughts that bother you Often lose your temper Excessive 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 you Depressed Mood Hopelessness Mood Swings Social Isolation Grief Poor Grooming Appetite Disturbance Feel depressed most of the day, nearly every day. Changes in sleep Elavated Mood Withdrawn Feeling Inadequate Have less interest/pleasure in doing things you usually enjoy doing Feel fatigued nearly every day. Feel worthless or excessively guilt most of the time. Have a difficult time thinking/concentrating, or feel indecisive a lot Have 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 suicide Delusions Often 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 mistakes Ever been diagnosed with ADHD? Often make careless mistakes? Often don’t finish assignments. Often distracted when listening to people Have trouble organizing tasks? Avoid things that take you a long time? Easily distracted by stuff going on around you Often forgetful Poor Memory Often fidget Often feel restless Often “on the go,” can’t sit still long Often talk too much Have trouble waiting your turn Often blurt out the answers to questions Interrupt a lot Physical Trauma Perpetrator Physical Trauma Victim Sexual Trauma Perpetrator Sexual Trauma Victim Sexually Acting out Substance AbuseSexual Dysfunction Emotional Trauma Perpetrator Emotional Trauma Victim Self Injury
Anything else we should know about you?
Family History
Who lives in your household?
Has your mother abused substances in the past/currently?

yes no
Which substance?
Has your father abused substances in the past/currently?

yes no
Which substance?
Has your sibling abused substances in the past/currently?

yes no
Which substance?
Has your mother been diagnosed with a mental disorder in the past/currently?

yes no
Which substance?
Has your father been diagnosed with a mental disorder in the past/currently?

yes no
Which substance?
What are your goals for therapy? *
Should be Empty:

Have you ever felt of experienced any of the following?

Family History