Form30 - [FORM 30-Use the top of this page for your...

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[ FORM 30 —Use the top of this page for your letterhead.] Adult Checklist of Concerns Name: Date: Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other concerns or issues.” You may add a note or details in the space next to the concerns checked. (For a child, mark any of these and then complete the “Child Checklist of Characteristics.”) q I have no problem or concern bringing me here q Abuse—physical, sexual, emotional, neglect (of children or elderly persons), cruelty to animals q Aggression, violence q Alcohol use q Anger, hostility, arguing, irritability q Anxiety, nervousness q Attention, concentration, distractibility q Career concerns, goals, and choices q Childhood issues (your own childhood) q Codependence q Confusion q Compulsions q Custody of children q Decision making, indecision, mixed feelings, putting off decisions q Delusions (false ideas) q Dependence q Depression, low mood, sadness, crying q Divorce, separation
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This note was uploaded on 07/01/2010 for the course COUN 6682 A and taught by Professor All during the Spring '10 term at Walden University.

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Form30 - [FORM 30-Use the top of this page for your...

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