Aspire Counseling and Clinical Consultation, PLLC

Adolescent Checklist of Concerns 

Name: _________________________________________ Date: ___________________________
Please mark all the items below that apply and feel free to add any others at the bottom under “Any other concerns or issues”.

❑ Abuse—physical, sexual, emotional, neglect,cruelty to animals 
❑ Aggression, violence 
❑ Alcohol use 
❑ Anger, hostility, arguing, irritability 
❑ Anxiety, nervousness, tension 
❑ Attention, concentration, distractibility 
❑ Career concerns, goals, and choices   
❑ Confusion 
❑ Decision making, indecision, putting off decisions  
❑ Depression, low mood, sadness, crying 
❑ Difficulty getting along with others 
❑ Drug use—prescription medications, over-the-counter medications, street drugs 
❑ Eating problems—overeating, undereating, appetite, vomiting  
❑ Family conflict 
❑ Fatigue, tiredness, low energy 
❑ Fears, phobias 
❑ Financial or money troubles, debt, impulsive spending, low income (self or family)
❑ Grieving, mourning, deaths, losses, divorce 
❑ Guilt
❑ Health, illness, medical concerns, physical problems (self or family)
❑ Homicidal thoughts ❑ Current   ❑ History of
❑ Inferiority feelings  
❑ Impulsiveness, loss of control, outbursts 
❑ Judgment problems, risk taking 
❑ Legal matters 
❑ Loneliness  
❑ Memory problems 
❑ Mood swings 
❑ Motivation 
❑ Obsessions, compulsions (thoughts or actions that repeat themselves) 
❑ Oversensitivity to rejection
❑ Panic or anxiety attacks 
❑ Perfectionism 
❑ Procrastination, work inhibitions, laziness 
❑ Relationship problems (with friends, with relatives, with classmates or co-workers) 
❑ School problems  
❑ Self-esteem 
❑ Self harming (cutting, burning)
❑ Self-neglect, poor self-care 
❑ Sexual issues  
❑ Shyness 
❑ Sleep problems—too much, too little, insomnia, nightmares 
❑ Stress, relaxation, stress management, stress disorders, tension 
❑ Suspiciousness, distrust 
❑ Suicidal thoughts ❑ Current  ❑ History of
❑ Temper problems, self-control, low frustration tolerance 
❑ Threats, violence 
❑ Weapons in household ❑ locked ❑ ammunition locked in separate cabinet than weapon  
❑ Withdrawal, isolating 
❑ Work problems, employment 
❑ Other concerns or issues: ______________________________ 

This is a strictly confidential patient medical record. Redisclosure is expressly prohibited by law without written permission of the client