Full Name: Preferred Name: Contact Email: Contact Phone: 1. How many days have you been unexpectedly absent or tardy from work/school in the last 30 days? 2. Do you have any current or history of medical conditions/illnesses? 3. Are you having difficulty sleeping or staying asleep? YesNo 4. Have you moved in the last 2 years? YesNo 5. Have you changed jobs in the last 2 years? YesNo 6. Have you experienced a recent death of someone close? YesNo 7. Have you or others been concerned about your alcohol or drug use? YesNo 8. Do you starve yourself, or make yourself throw up? YesNo 9. Are you very concerned about your weight? YesNo 10. Do you self-injure? YesNo 11. Do you have any suicide thoughts or past attempts? YesNo 12. Do you have any thoughts about hurting others? YesNo 13. Do you feel you are in danger of being hurt? YesNo 14. Do you have extreme irritability or outbursts of anger? YesNo 15. Do you have problems in your relationships with other people? YesNo 16. Do you tend to act or speak before thinking (poor impulse control)? YesNo 17. Do you have sexual concerns? YesNo 18. Do you hate going to work? YesNo 19. Are you experiencing financial problems? YesNo 20. Have you had any legal problems? YesNo 21. Do you have excessive fears, worries, or nervousness? YesNo 22. Do you prefer not to participate in community or social activities? YesNo 23. Have you lost hope that your problem can be resolved? YesNo 24. Do you have very low or high energy? YesNo Other issues needing to be discussed:
