Roberta M. Faust, LMFT #49048
4125 Blackford Ave, # 215
San Jose, CA 95117

Adult 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.” You may add a note or details in the space next to the concerns checked.
 
       Abuse—physical, sexual, emotional
       Aggression, violence      
       Alcohol  or Drug use (OTC/Prescription/Illegal)
       Anger, hostility, arguing, irritability      
       Anxiety, nervousness        
       Attention, concentration, distractibility 
      Career concerns, goals, and choices   
      Childhood issues (your own childhood)    
      Confusion 
      Compulsions 
	 Custody of children           
      Decision making, indecision, mixed feelings, putting off decisions 
      Dependence    
      Depression, low mood, sadness, crying 
      Divorce, separation            
      Eating problems—overeating, undereating, appetite, vomiting (see also “Weight and diet issues”) 
      Emptiness	
      Fatigue, tiredness, low energy          
      Fears, phobias 
      Financial or money troubles, debt, impulsive spending, low income 
      Friendships     
      Gambling     
      Grieving, mourning, deaths, losses, divorce 
      Guilt        
      Headaches, other kinds of pains          
      Health, illness, medical concerns, physical problems 
      Inferiority feelings 
      Interpersonal conflicts 
      Impulsiveness, loss of control, outbursts 

FORM 29. Adult checklist of concerns (p. 1 of 2). 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). 
Adult Checklist of Concerns (p. 2 of 2) 

      Judgment problems, risk taking 
       Legal matters, charges, suits 
       Loneliness/Isolation 
      Marital conflict, distance/coldness, infidelity/affairs, remarriage, different expectations, disappointments 
      Memory problems 
      Mood swings 
      Motivation, laziness 
      Nervousness, tension 
      Obsessions, compulsions (thoughts or actions that repeat themselves) 
      Oversensitivity to rejection 
      Pain, chronic
      Panic or anxiety attacks 
      Parenting, child management, single parenthood 
      Perfectionism 
      Pessimism 
      Procrastination, work inhibitions, laziness 
      Relationship problems (with friends, with relatives, or at work) 
      School problems (see also “Career concerns ...”) 
      Self-esteem 
      Self-neglect, poor self-care 
      Sexual issues, dysfunctions, conflicts, desire differences, other 
      Shyness, oversensitivity to criticism 
      Sleep problems—too much, too little, insomnia, nightmares 
      Smoking and tobacco use 
      Spiritual, religious, moral, ethical issues 
      Stress, relaxation, stress management, stress disorders, tension 
      Suspiciousness, distrust 
      Suicidal thoughts 
      Temper problems, self-control, low frustration tolerance 
      Thought disorganization and confusion 
      Threats, violence 
      Weight and diet issues 
      Withdrawal, isolating 
      Work problems, employment, overworking, can’t keep a job, dissatisfaction, ambition 
      Other concerns or issues: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please look back over the concerns you have checked off and choose the one that you most want help with.