Adolescent Supplemental Information
2611 Washington St, Pella, IA 50219 I 641-628- 9599 I 1701 48th St, Ste 120, West Des Moines, IA 50266 I 515-331-0303
Name
First Name
Last Name
Date of birth
/
Month
/
Day
Year
Date
Why did you come today?
Whose idea was it that you come?
Please check those that apply to you:
I'm sad or unhappy most of the time
I don't enjoy things I used to
My appetite/weight has changed
I'm sleeping too much
I'm not sleeping/can't sleep
I feel restless
I feel sluggish/slowed down
I'm tired or low on energy
I feel worthless or guilty
It is hard to concentrate
I cry alot/easily
I'm not motivated
I feel helpless or hopeless
I worry alot
I feel moody
I often feel angry or irritable
I have a hard time making decisions
I have aches, pain and headaches
I have flashbacks
I have nightmares
I'm easily startled
I don't like going new places
I'm a people pleaser
I'm afraid of failing/being rejected
I tend to withdraw/spend time alone
I'm sensitive to criticism
I tend to obsess or be perfectionistic
Please check any Compulsive Behaviors you might have:
Counting
Checking
Hand washing/cleaning
Praying
Nail biting/hair pulling/skin picking
Other
Check any Panic symptoms you might have:
Panic attacks
Racing heart rate
Sweating
Trembling
Shortness of breath
Feelings of choking
Chest pain
Nausea
Feeling dizzy
Chills
Numbness/tingling
Feeling detached
Fear of going "crazy" or dying
Check more of the options below that apply to you.
I think very highly of myself
I don't need much sleep
I talk too much/feel like I have to talk
My ideas go all over the place
I take too many risks
I can't pay attention/get distracted
I'm not organized/I'm messy
I can't follow directions
I often lose things
I often forget things and need reminders
I feel on the go all the time
I tend to figit/it is hard to sit still
I act without thinking
I get bored easily
I like to be center of attention
I don't finish things I start
I often daydream
I'm told I'm bossy
I've been bullied
My classmates think I'm weird
I don't have many friends
I wish I had more friends
I don't eat much because I don't want to gain weight
I don't like how my body looks
I eat way more than I should
I try to "make up" for eating (vomiting, exercising, laxatives)
I don't trust other easily
I feel people are out to get me
I see/hear things others do not
It is hard to know what is real or not
I hate going to/have skipped school
I get in trouble/break rules at school
I have conflict with my teachers
I am disappointed with my grades
Others are disappointed in my grades
Homework is difficult for me
I can't think when I take tests
I get in trouble/break rules at home
I've thought about running away
I talk back to adults/my parents
I'm not very trustworthy/I lie alot
I've stolen/shoplifted
I've vaped/smoked cigarettes
I've drank alcohol
I've used marijuana or other drugs
My friends vape/use alcohol/drugs
I've been in trouble with the police
I have concerns about sex/sexuality
I've been the victim of sexual abuse
I've looked at pornography
I have low self esteem
I've hurty myself (cut, burned, etc)
I've thought about/attempted suicide
Are there any other concerns not listed above you want to discuss?
What are some things you are good at? (Strengths? Favorite things?)
What are some things you're not very good at? (Weaknesses? Least favorite things?)
Do you have at least one friend who you really like and feel you can talk to?
Yes
No
Not sure
Do you think that your parents really listen to you and take your feelings seriously?
Yes
No
Not sure
What do you like about your family?
What do you dislike about your family?
Have you had fun in the last two weeks?
Yes
No
If yes, what were you doing to have fun?
What words would you use to describe yourself?
If you could change one thing about your life or yourself, what would it be?
What do you like about school?
What do you dislike about school?
How do you feel about your teachers?
What extracurricular activities are you involved in ?
Do you have a phone?
If yes, what social media apps do you use?
Do you play video games?
If yes, what games do you play?
Anything else you would like us to know about you or your situation?
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