*Please look back over the concerns you have checked off and circle the one that you need the most help with




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Teen Checklist of Concerns


Name: __________________________________________________ Date: ____________________________________


Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other concerns or issues.”


❑ I have no problem or concern bringing me here

❑ Abuse—physical, sexual, emotional, neglect (of children or elderly persons), cruelty to animals

❑ Aggression, violence

❑ Alcohol use

❑ Anger, hostility, arguing, irritability

❑ Anxiety, nervousness

❑ Attention, concentration, distractibility

❑ Confusion

❑ Decision-making, indecision, mixed feelings, putting off decisions

❑ Dependence on another person

❑ Depression, low mood, sadness, crying

❑ Divorce or separation (parents)

❑ Drug use—prescription medications, over-the-counter medications, street drugs

❑ Eating problems—over-eating, under-eating, appetite, vomiting (see also “Weight and diet issues”)

❑ Emptiness

❑ Failure

❑ Fatigue, tiredness, low energy

❑ Fears

❑ Friendships

❑ Grieving, mourning, deaths, losses

❑ Guilt

❑ Headaches, other kinds of pains

❑ Health, illness, medical concerns, physical problems

❑ Housework/chores—quality, schedules, sharing duties

❑ Impulsiveness, loss of control, outbursts


❑ Judgment problems, risk taking

❑ Loneliness

❑ Memory problems

❑ Mood swings

❑ Motivation, laziness

❑ Nervousness, tension

❑ Obsessions, compulsions (thoughts or actions that repeat themselves)

❑ Oversensitivity to rejection

❑ Panic or anxiety attacks

❑ Perfectionist

❑ Procrastination, work inhibitions, laziness

❑ Relationship problems

❑ School problems

❑ Self-centeredness

❑ Self-esteem

❑ Sexual issues

❑ Shyness, oversensitivity to criticism

❑ Sleep problems—too much, too little, can’t fall asleep, nightmares

❑ Smoking and tobacco use

❑ Spiritual, religious, moral, ethical issues

❑ Stress

❑ Thoughts of hurting self

❑ Temper problems, gets angry easily

❑ Threats, violence

❑ Weight and diet issues

❑ Please list any other concerns or issues: ______________________________________________________________________


__________________________________________________________________________________________________________


*Please look back over the concerns you have checked off and circle the one that you need the most help with.


FORM 29. From The Paper Office. Copyright 2003 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of this book for personal

use only (see copyright page for details).

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