Please answer these questions based on the last 24 hours, or the weekend, if it's Monday.

Do not include any personally identifiable information. When the form is completed, you will receive a code to provide to your counselor.

Today

Today's Goal:

Did you achieve your goal from yesterday?

Yes

If not, what got in your way?

Anxiety Rating (0-10):

Depression Rating (0-10):

Select what you are currently experiencing.

trouble focusing

poor motivation

panic attacks

racing thoughts

nervous

hypervigilance

aggressive outbursts

poor hygiene

judged

paranoid

sad

numb

scared

irritable

tired

unsure

unsafe

hopeless

foggy

lonely

gloomy

worthless

anxious

empty

panicked

exhausted

unhappy

stressed

confused

concerned

uneasy

worried

miserable

defeated

frustrated

angry

joyful

excited

refreshed

hopeful

loved

accepted

forgiven

thankful

patient

appreciated

seen

heard

happy

peaceful

content

safe

What would you like to talk about today?

How can the group best support you?

Have you showered/bathed in the last 24 hours?

Yes

Have you brushed your teeth in the last 24 hours?

Yes

How many hours of sleep did you get last night?

Sleep comments?

I can't fall asleep

I can't stay asleep

bedwetting

nightmares

trouble waking up

I feel rested

I feel tired

restlessness

racing thoughts

Meals

Did you eat breakfast?

Yes

What did you eat for breakfast?

Did you eat lunch?

Yes

What did you eat for lunch?

Did you eat dinner?

Yes

What did you eat for dinner?

Did you snack?

Yes

What did you snack on?

Eating comments?

not hungry

restricting

hoarding food

bingeing

purging

snacking

3 balanced meals

no issues

increased appetite

no appetite

no change

Are you taking your meds as prescribed?

Yes

Are you having any substance use cravings?

Yes

Rate your cravings:

0/None

10/High

Cravings comments?

cigarettes

vape

alcohol

marijuana

pills

cocaine

heroin

other

Have you used any substances in the last 72 hours?

Yes

Substances used?

cigarettes

vape

alcohol

marijuana

pills

cocaine

heroin

other

Are you seeing or hearing things that others do not?

Yes

What are you experiencing?

Thoughts of Killing

Do you have any thoughts of killing someone else?

Yes

*If yes, please rate the intensity of your thoughts.

0/None

10/High

Do you have a plan for how to kill them?

Yes

Do you have intent to follow through with it?

Yes

*If yes, please rate the intensity of your intent.

0/None

10/High

Self Harm

Have you been having urges to self-harm?

Yes

How intense are these urges?

0/None

10/High

How often do you have these urges?

1 x per day

3-5 x per day

5 x per day

All day

Which coping skills helped prevent you from acting on these urges?

Have you acted on these urges and self-harmed in the past 24 hours?

Yes

Where on your body did you self-harm?

What was the purpose of you self-harming?

Do you still have access to anything you used (other than your own body) to self-harm?

Yes

Do you have an "Accountability Partner" for self- harming? Have you talked to them about this incident?

Yes

Columbia-Suicide Severity Rating Scale (C-SSRS)

Within the last 24 hours:

1. Wish to be dead: Have you wished you were dead or wished you could go to sleep and not wake up?

Yes

2. Current suicidal thoughts: Have you actually had any thoughts of killing yourself?

Yes

3. Suicidal thoughts w/ Method w/ no specific Plan or Intent to act): Have you been thinking about how you might do this?

Yes

4. Suicidal Intent without Specific Plan: Have you had these thoughts and had some intention of acting on them?

Yes

5. Intent with Plan: Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan?

Yes

6. If you answered "Yes" to questions 3 or 5, what is your method or plan?

7. Have you ever done anything, started to do anything, or prepared to do anything to end your life? Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn't jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.

Yes

Adult Check-in Form