Symptoms Client's Name(Required) First Last This field is hidden when viewing the formEmail Please check the symptoms you are having now: Aches/pains Forgetful Nightmares Anxious/nervous Frequent mood swings Numbness/tingling Ashamed Frustration Physical aggression/cruelty animals Blames others Guilt feelings Poor concentration Body image concerns Headaches Poor memory Can’t enjoy myself Hear voices Racing thoughts Choking feeling Heart racing Repetitive actions Cry easily/often Heavy feeling Restless/fidgety Depressed/sad Hoarding Seeing images or objects Destroys property/set fires Hopelessness Self-harming behaviors/urges Difficulty breathing Hyperactivity Sexual issues/concerns Distressing memories Impulsive Shaking Disturbing thoughts Irritable/angry Sleep problems Dizziness Lack of motivation Social discomfort Eating/appetite concerns Lies/steals Tense feelings Elevated mood Loneliness Thoughts of wanting to die Excessive worry Lose temper Thoughts of wanting to hurt others Feel inferior Low energy/tired Wound up Feel unworthy Low self-esteem Feeling paranoid/suspicious Motor or verbal tics None reported Areas that have been impaired by the symptoms: Coping skills Health Occupational functioning Daily living skills Housing/shelter Self-protection/personal safety Economic/financial impairment Legal difficulties Sexual functioning Educational/school function Marital/family conflict or dysfunction Socialization
