INDIVIDUAL CONCERNS
Check all symptoms that have been present within the past 3 months
☐Nervous
☐Health Problems
☐Marital Problems
☐Drug Usage
☐Shy
☐Stomach Problems
☐Divorce
☐Alcohol Usage
☐Anger
☐Bowel Problems
☐Separation
☐Financial Problems
☐Loneliness
☐Depression
☐Affair
☒Socialization issues
☐Frustration
☐Headaches
☐Problems w/ ex-spouse
☐No Energy
☐Temper
☐Memory Loss
☐Stress
☐Tired
☐Self-Control
☐Sleeping Problems
☐Grief
☐Children
☐Insecurity
☐Nightmares
☐Parenting Problems
☐Career Choices
☐Fears
☐No Ambition
☐Relationship Problems
☐Family Conflict
☐Panic Attacks
☐Eating Problems
☐Legal Problems
☐Chronic Pain
☐Isolation
☐Suicidal Thoughts
☐Work Problems
☐Lack of fulfillment
☐Weight Gain/Loss
☐Mood Swings
☐Low Self-Esteem
☐Lack of motivation
6400 W. 110th St., Ste 203
Leawood, KS 66211
913.735.6093
www.healthyrootscounseling.com
[email protected]