Self Assessment Form - Cbt Pinellas
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2Name: ____________
Date of completion: ____________
Self Assessment Form
W hat is happening in your life which resulted in this appointment? What would you like to see accomplished in therapy?
_____________________________________________________________________________________________________
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CHIEF COMPLAINTS
Check all that apply and please add a brief description if possible
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Depression: _____________________________________________________________________________
Low energy/fatigue: _______________________________________________________________________
Low self-esteem: __________________________________________________________________________
Poor concentration:_____________________________________________________________________
Hopelessness: ____________________________________________________________________________
Addiction issues: _________________________________________________________________________
Obsessions/compulsive behaviors: ___________________________________________________________
Thoughts racing/can’t hold onto an idea: ______________________________________________________
Eating Problems (over/under/obesity): ________________________________________________________
School/work problems: ____________________________________________________________________
Excessive or impulsive behaviors: ___________________________________________________________
Delusions/hallucinations: __________________________________________________________________
Not thinking clearly/confusion: _____________________________________________________________
Difficulty trusting others: __________________________________________________________________
Feeling that you/things around you are not real: ________________________________________________
Lose track of time:_______________________________________________________________________
Unpleasant thoughts won't go away: _________________________________________________________
Anger/frustration management problems: _____________________________________________________
Easily agitated/annoyed: __________________________________________________________________
Defies rules/blames others: ________________________________________________________________
ADHD symptoms: _______________________________________________________________________
Argues: ________________________________________________________________________________
Excessive use of drugs and/or alcohol: ________________________________________________________
Excessive use of prescription medications: _____________________________________________________
Blackouts: ______________________________________________________________________________
Flashbacks (not drug related): _______________________________________________________________
Domestic violence issues: __________________________________________________________________
Relationship, marital or family problems: ______________________________________________________
Sexual or physical abuse or neglect issues : _____________________________________________________
Other trauma history (accident, fire, etc.): ______________________________________________________
Suicidal thoughts/actions (circle): ____________________________________________________________
Self-harm thoughts/actions (circle): ___________________________________________________________
Worthlessness: ____________________________________________________________________________
Guilt___________________________________________________________________________________
Sleep disturbance (more/less): ____________________________________________________________
Appetite disturbance (more/less): _________________________________________________________
Aggressive behaviors: _________________________________________________________________
Thoughts of hurting someone: ___________________________________________________________
Isolation/social withdrawal: _____________________________________________________________
Sadness/loss: ______________________________________________________________________________
Beth Lewis, LMHC
(727) 463-1938 FAX (877) 240-7970
th
11380 66
St North Suite #135 Largo, Florida 33773
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