Printable PDF version: Counseling Problem Checklist
Name: _________________________
Age: __________ Date filled out: _____________
Check any of the following problems that you experience:
| _____ | Depression | _____ | Feeling that you are not real |
| _____ | Low energy | _____ | Feeling that things around you are not real |
| _____ | Low self-esteem | _____ | Lose track of time |
| _____ | Poor concentration | _____ | Unpleasant thoughts won’t go away |
| _____ | Hopelessness | _____ | Anger management/frustration |
| _____ | Worthlessness | _____ | Easily agitated/annoyed |
| _____ | Guilt | _____ | Difficulty with rules/submitting to authority |
| _____ | Sleep disturbance (more/less) | _____ | Habit blaming others |
| _____ | Appetite disturbance (more/less) | _____ | Tend to Argue & be defensive |
| _____ | Thoughts of hurting yourself | _____ | Excessive use of drugs and/or alcohol |
| _____ | Thoughts of hurting someone | _____ | Excessive use of prescription medications |
| _____ | Isolation/social withdrawal | _____ | Blackouts |
| _____ | Sadness/loss | _____ | Physical abuse issues |
| _____ | Stress | _____ | Sexual abuse issues |
| _____ | Anxiety/panic | _____ | Spousal abuse issues |
| _____ | Heart pounding/racing | _____ | Loneliness |
| _____ | Chest pain | _____ | Nightmares |
| _____ | Trembling/shaking | _____ | Intrusive thoughts |
| _____ | Sweating | _____ | Headaches |
| _____ | Chills/hot flashes | _____ | Sexual problems |
| _____ | Tingling/numbness | _____ | Suicidal thoughts |
| _____ | Fear of dying | _____ | Relationship problems |
| _____ | Nausea/Stomach Problems | _____ | Difficult relaxing |
| _____ | Phobias | _____ | Compulsive behaviors |
| _____ | Obsessive thoughts | _____ | Marital/family problems |
| _____ | Thoughts racing | _____ | Poor impulse control |
| _____ | Can’t hold onto an idea | _____ | Confusion |
| _____ | Easily agitated | _____ | Difficulty trusting |
| _____ | Excessive behaviors (spending, gambling) | _____ | Not thinking clearly/confusion |
| _____ | Delusions/hallucinations | _____ | Spiritual Issues: |
| _____ | Other problems/symptoms: | _____ | Pain (where): |