Pre-Session Screening Form
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Notice: This is not a 100% encrypted secure form, it does fall under CSJ's Google Workspace HIPPA compliance. It is intended to collect brief information to prepare for the session.  If you are concerned with keeping this information private, no worries, please contact the counselor by phone. If you choose to complete this form, your data will be stored in your clinical file by the professionals at Creating Sustaining Joy, LLC.  
1).  RATE PSYCHOLOGICAL PAIN (hurt, anguish, or misery in your mind, hopelessness, overwhelm, etc.) *
Low Pain
Great Pain
What I find most painful is...
2).  RATE YOUR EATING PATTERNS THIS WEEK (Good = eating at least 2 regular healthy meals a day with little junk food/snacking, no binging): *
Good Eating Habits
Poor Eating Habits
What is the biggest barrier to eating better: *
3). RATE AGITATION (emotional urgency, frustration, irritation; annoyance): *
Low Agitation
High Agitation
I am most agitated with (school, work, etc): *
4).  RATE SELF-CARE (ability to address hygiene/grooming, housekeeping, completing to-dos): *
Great Self-Care
Poor Self-Care
Which area of self-care are you struggling with the most? *
5).  RATE OF CARE OF HEALTH CONDITIONS (taking prescribed medications on schedule, checking blood sugars, f/u with doctors, etc. ): *
Good Care of Health/No Health Conditions
Poor Care
What are the barriers to caring for my health? *
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