Is individual coming late, leaving early, missing days/taking days off?
Having difficulty focusing?
Is work performance, quality, or speed suffering?
Is individual unable to perform tasks?
Have emotions been erupting at work (e.g. anger outbursts, crying, or snapping at coworkers)?
Is individual having issues with coworkers? Is the individual's job in jeopardy?
Is this individual having trouble keeping jobs, or having difficulty looking for work?
Has school attendance, performance, work quality, or grades been affected?
Is individual meeting deadlines?
Has anyone at school noticed a change in individual's behavior?
Have there been inappropriate behaviors/emotions in the classroom/workplace?
Is individual skipping meals, binging, or eating in an unhealthy manner?
Has anyone noticed weight loss or gain?
Is individual getting out of bed, taking a shower, and getting dressed as often as before?
Has individual stopped brushing hair or wearing makeup, or doing other usual self-care rituals (ex. exercise, therapy, meditation)?
Is individual having trouble managing finances and paying bills?
Maintaining home (e.g. cleaning, laundry, dishes, shopping, and meal preparation)?
Is the individual managing mail, phone and email?
Is the individual filling medications, and taking as directed?
Are relationships with parents, children, and partner affected?
Is individual more irritable/impatient with them? Is individual engaging less with family?
Is individual unable to perform usual responsibilities, so others must take these on?
Have friendships been affected? Has the individual become withdrawn, or more dependent?
Does the individual have few friends, perhaps due to mental health issues?
Has the individual stopped attending social, community, or religious activities?
If dating, has this been affected?
Has health been affected -- ex. pain, headaches, stomach issues, tension-related body aches?
Is anxiety or denial causing individual to avoid seeking medical help, or to not follow doctors' recommendations?
How many hours of sleep is individual averaging? Document frequency of hypersomnia as well as difficulty falling asleep, staying asleep, nightmares, and daytime drowsiness.
Is individual falling asleep at work?
Is individual engaging in self-destructive financial behavior, such as compulsive buying,
overspending, or pathological gambling?
Is the individual paying their bills or are they struggling financially with increased debt?
Has there been an increase in the individual's use of cigarettes, alcohol, marijuana, or other drugs, perhaps related to mental health issues?
Has individual had negative consequences, or are others worried about his/her use?
Is individual taking prescriptions in any way other than prescribed? Has the individual incurred driving tickets from substances and/or speeding issues?
Is the individual more irritable or sad?
Is the individual withdrawing from others?
Is the individual avoiding specific calls or struggling more specific calls? Is the individual volunteering more for high risk calls?
Is the individual joking about self-harm or being worth more dead than alive?
© Copyrighted material
Do not copy, reproduce or paste without written authorization from Dr. Adler-Tapia