GRID
You will be presented with a series of problems that people sometimes have. Read each item carefully and indicate your present level of concern about the item. Please answer questions as honestly as possible.
Initials and date of birth *
XYZ MM/DD/YY
Your answer
1. Difficulty concentrating *
No Concern
Most Concerned
2. Discrimination or harassment *
No Concern
Most Concerned
3. Feelings of failure *
No Concern
Most Concerned
4. Conflict in relationship *
No Concern
Most Concerned
5. Feeling left out of things *
No Concern
Most Concerned
6. Mood swings *
No Concern
Most Concerned
7. Sexual assault or abuse *
No Concern
Most Concerned
8. Physical abuse or assault *
No Concern
Most Concerned
9. Lack of life goals or purpose *
No Concern
Most Concerned
10. Internal conflict or confusion *
No Concern
Most Concerned
11. Pain *
No Concern
Most Concerned
12. Sexual concerns *
No Concern
Most Concerned
13. Difficulty with children *
No Concern
Most Concerned
14. Being laughed at or criticized *
No Concern
Most Concerned
15. Financial problems *
No Concern
Most Concerned
16. Problems sleeping *
No Concern
Most Concerned
17. Feelings of fear or panic *
No Concern
Most Concerned
18. Family conflict *
No Concern
Most Concerned
19. Unable to forget past mistakes *
No Concern
Most Concerned
20. Nervous around people *
No Concern
Most Concerned
21. Nightmares *
No Concern
Most Concerned
22. Conflict with others *
No Concern
Most Concerned
23. Feeling hopeless *
No Concern
Most Concerned
24. Difficulty reaching goals *
No Concern
Most Concerned
25. Problems at work *
No Concern
Most Concerned
26. Poor eating habits *
No Concern
Most Concerned
27. Church attendance *
No Concern
Most Concerned
28. Health problems *
No Concern
Most Concerned
29. Having very unusual experiences *
No Concern
Most Concerned
30. Worried about a family member *
No Concern
Most Concerned
31. Hear or see things other people don't see or hear *
No Concern
Most Concerned
32. Death *
No Concern
Most Concerned
33. Boredom *
No Concern
Most Concerned
34. Feeling like things are not real *
No Concern
Most Concerned
35. Distrust of others *
No Concern
Most Concerned
36. Lack of exercise *
No Concern
Most Concerned
37. Unhappy too often *
No Concern
Most Concerned
38. Fear of insanity *
No Concern
Most Concerned
39. Concern about physical appearance *
No Concern
Most Concerned
40. Thinking about same thing over and over *
No Concern
Most Concerned
41. Crying *
No Concern
Most Concerned
42. Anger *
No Concern
Most Concerned
43. Recent difficult changes *
No Concern
Most Concerned
44. Want to die *
No Concern
Most Concerned
45. Difficulty coping *
No Concern
Most Concerned
46. Good relationship with God *
No Concern
Most Concerned
47. Loneliness *
No Concern
Most Concerned
48. Unloveable *
No Concern
Most Concerned
49. Memory problems *
No Concern
Most Concerned
50. Alcohol or drug use *
No Concern
Most Concerned
51. Need to be perfect *
No Concern
Most Concerned
52. Stupid people *
No Concern
Most Concerned
53. Problem with body weight *
No Concern
Most Concerned
54. Lack of self-control *
No Concern
Most Concerned
55. Disappointed with yourself *
No Concern
Most Concerned
56. Feeling like you don't fit-in *
No Concern
Most Concerned
57. Racing thoughts *
No Concern
Most Concerned
58. Difficulty speaking up *
No Concern
Most Concerned
59. No one to talk with *
No Concern
Most Concerned
60. Others concerned about my drug or alcohol use *
No Concern
Most Concerned
61. Unable to relax *
No Concern
Most Concerned
62. Emotional abuse *
No Concern
Most Concerned
63. Feeling out of control *
No Concern
Most Concerned
64. Too busy *
No Concern
Most Concerned
65. Legal problems *
No Concern
Most Concerned
66. Guilt *
No Concern
Most Concerned
67. Thoughts of killing or hurting someone *
No Concern
Most Concerned
68. Fatigue *
No Concern
Most Concerned
69. Low self-esteem *
No Concern
Most Concerned
70. Habits interfere with daily activities *
No Concern
Most Concerned
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