Marchants House Therapy Centre

CONFIDENTIAL

What are your concerns?*

Please choose the words and their frequency that best describe him/ her*:

	Sometimes	Often	Never			Sometimes	Often	Never
Cheerful					Demonstrative
Tearful					Gloomy
Angry					Happy
Frustrated					Impatient
Confident					Lonely
Sulky					Poor sleeper
Shy					Anxious
Outgoing					Bossy
Clingy					Timid
Sensitive					Excitable
Sad					Prone to nightmares
Fearful					Possessive
Jealous					Worrier
Argumentative					Caring
Domineering					Fun-loving

Any medical problems/ medication?* Yes No
(if yes, please give details)