List Client & family symptoms Indicate how often symptoms are experience > O= Often S= Sometimes N= Never
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Symptoms
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Who
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How Often
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Date started
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Who
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How often
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Date Started
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Suicidal thoughts
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Suicidal Plan ____ attempts ___
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Purposely hurt self
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Purposely hurt someone else
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Accused of Sexual abuse
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Anxiety____ Panic attacks____
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Hyper __ Manic _____
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Thinks someone out to get them
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Depressed loss of interest in life
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Sadness ___ Crying __
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Irritable crabby
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Isolated withdrawn
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Hears or sees things no one else
does
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Overly self critical
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Overly critical of others
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Excessively loud or talkative
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Eats non nutritive substances
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Pick at body or pulls hair
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Anger Outburst
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Easily frustrated
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Excessive involvement in
pleasurable activities
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Rapid change in moods
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Night mares
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Go with out sleep
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Sleep excessively how much?
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Eat too little ___ to much___
stomach pain ______
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Vomiting ___ Binging____
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Act before thinking
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Learning difficulty
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Forgetful
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Problem concentrating
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Always moving
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Weight loss _____ gain____
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Blames other for their behaviors
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Refused to do as asked
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Physically aggressive
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Verbally aggressive
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List Client & family symptoms Indicate how often symptoms are experience > O= Often S= Sometimes N= Never
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Bullies, intimidates,threatens
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Sexual knowledge above _____
below expected level ________
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Feel excessively guilty
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Been stalked or stalked anyone
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Been in relationship with
someone your afraid of
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Regressed behaviors
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Repetitive behaviors
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Rituals
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Behaviors tried to stop couldn't
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Difficulty moving from one
activity to another
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Upsetting memories
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Nervous ___ worry ___
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Make poor eye contact
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Clingy with care givers
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Feel frightened
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Feeling numb
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Repeats same words frequently
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People take advantage of me
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Avoid social situation
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Wetting _____ Soiling______
Night _________ Day ______
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Overly sensitive to sound, light,
touch
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Inappropriate sexual activities
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