Covenant Counseling • 212 West Wackerly Rd., Suite 200 • Midland, MI 48640

(989) 835-8344

Mon - Fri 9:00 AM - 5:00 PM

Counseling Problem Checklist

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):