Therapy Adolescent Supplemental Information

Adolescent Intake Supplemental Information
2611 Washington St, Pella, IA 50219, 641-628- 9599

1701 48th St, Ste 120, West Des Moines, IA 50266, 515-331-0303
Name:

First NameLast Name
Date of birth:

MonthDayYear
Date
Why are you coming for an appointment?
Whose idea was it that you come?
Please check those that apply to you:

I'm sad or unhappy most of the timeI don't enjoy things I used toMy appetite/weight has changedI'm sleeping too muchI'm not sleeping/can't sleepI feel restlessI feel sluggish/slowed downI'm tired or low on energyI feel worthless or guiltyIt is hard to concentrateI cry a lot/easilyI'm not motivatedI feel helpless or hopelessI worry a lotI feel moodyI often feel angry or irritableI have a hard time making decisionsI have aches, pain, headachesI have flashbacksI have nightmaresI'm easily startledI don't like going new placesI'm a people pleaserI'm afraid of failing/being rejectedI tend to withdraw/spend time aloneI'm sensitive to criticismI tend to obsess or be perfectionistic
Check any Compulsive Behaviors you might have:

CountingCheckingHand washing/cleaningPrayingOther
Check any Panic symptoms you might have:

Panic attacksRacing heart rateSweatingTremblingShortness of breathFeelings of chokingChest painNauseaFeeling dizzyChillsNumbness/tinglingFeeling detachedFear of going "crazy" or dying
Check any of the options below that apply to you:

I bite my nails/pull hair out/pick skinI think very highly of myselfI don't need much sleepI talk too much/feel like I have to talkMy ideas go all over the placeI take too many risksI can't pay attention/get distractedI'm not organized/I'm messyI can't follow directionsI often lose thingsI often forget things and need remindersI feel on the go all the timeI tend to fidget/it is hard to sit stillI act without thinkingI get bored easilyI like to be center of attentionI don't finish things I startI often daydreamI'm told I'm bossyI've been bulliedMy classmates think I'm weirdI don't have many friendsI wish I had more friendsI don't eat much because I don't want to gain weightI don't like how my body looksI eat way more than I shouldI try to "make up" for eating (vomiting, exercising, laxatives)I don't trust other easilyI feel people are out to get meI see/hear things others do notIt is hard to know what is real or notI hate going to/have skipped schoolI get in trouble/break rules at schoolI have conflict with my teachersI am disappointed with my gradesOthers are disappointed in my gradesHomework is difficult for meI can't think when I take testsI get in trouble/break rules at homeI've thought about running awayI talk back to adults/my parentsI'm not very trustworthy/I lie alotI've stolen/shopliftedI've vaped or smoked cigarettesI've drank alcoholI've used marijuana or other drugsMy friends vape/use alcohol/drugsI've been in trouble with the policeI have concerns about sex/sexualityI've been the victim of sexual abuseI've looked at pornographyI have low self esteemI've hurt 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?

YesNoNot sure
Do you think that your parents really listen to you and take your feelings seriously?

YesNoNot sure
What do you like about your family?
What do you dislike about your family?
Have you had fun in the last two weeks?

YesNo
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?*
Should be Empty:

Adolescent Intake Supplemental Information