PGSP CLINIC: Client Intake Sheet



Treatment Goals: Please place a checkmark next to each of the following areas that you would like to work on improving at our Center. Academic/IntellectualInternalizingLife Challenges Other?Academic Achievement?Anxiety?Accepting Death?Eating Problems?Cognitive-Intellectual Functioning?Avoidance?Adjustment to Change?Gender Identity Problems?Learning Disorder,Underachievement?Compulsive Behavior?Burn Out ?Housing/Living Situation?School Involvement?Depressed Mood?Chaos & Order?Medication Adherence?School Refusal/Truancy?Enuresis, Encopresis?Contentment, Enjoyment, Happiness?Parenting Skills?Speech and Language Problems?Fears / Phobias?Early/Mid-Life Crisis?PsychosisSocial?General Life Stress?End of Life Issues?Self-Injurious Behavior?Assertiveness?Grief?Family Functioning?Sex/Pornography Addiction?Empathy?Low Self-Esteem?Guilt & Shame?Sexual Orientation?Positive Peer Interaction?Mania/Bipolar?Home/Identity/Belonging?Sleep Problems?Peer/Sibling Conflict?Shyness?Life Regrets?Work Stress ?Social Skills?Suicidality?Living In Fear?Other:Externalizing?Traumatic Stress?Lying/Telling the Truth?Other:?Aggression?Mother/Father Issues?Other:?Anger?Money Issues?Attention Problems?Positive Thinking/ Positive Attitude?Hyperactivity?Purpose & Meaning in Life?Oppositional/Non-Compliant Behavior?Risk Taking?Runaway?Self-Hatred?Sexual Misconduct?Self-Management/Self-Control?Substance Use?Self Sabotaging?Willful Misconduct, Delinquency?Trust Issues ................
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