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Stressor Checklist Name: _____________________________________ Date: _________________ Rate the level of distress you are currently experiencing by circling the appropriate number: No Distress 0 1 2 3 4 5 6 7 8 9 10 Extreme Distress Please read the following checklist and check once the items of concern to you. Check twice those items which are of most concern to you. Personal/Interpersonal: _______ values conflict _______ sexual concerns _______ long-distance relationship _______ anxious about meeting new people _______ lack of friends _______ too much social life _______ over reliance on others _______ not feeling good about appearance _______ wondering if I will find a suitable partner _______ significant other relationship problems _______ feeling lonely and isolated _______ feelings easily hurt by others ________ not trusting others _______ getting into arguments ________ fear being rejected _______ too easily led by other people _______ feeling that nobody understands _______ feeling discriminated against ________ lack assertiveness _______ not comfortable with current cultural surroundings ________ trouble socializing with others ________ difficulty getting over a relationship ________ abusive relationship ________ victim of past physical/sexual/verbal/emotional abuse ________ criminal/legal problems ________ excessive credit card debt ________ other financial concerns Family: ______ family death or illness ______ problems with parents/children/relatives _______ lack of family support Emotional: _______ feeling nervous/anxious _______ unhappy much of the time _______ feeling tired _______ emotional ups and downs ________ being impulsive _______ feeling as though life is not worth living _______ thoughts of harming others _______ thoughts of suicide ________ injuring self or thoughts of doing so ________ flashbacks of past trauma ________ recurrent thoughts, impulses or images that are intrusive or unwanted ________ worrying about unimportant things _______ feeling uncomfortable when alone ________ feeling that others are talking about me _______ difficulty controlling anger ________ feeling agitated/irritable Health/Physical: ________ use of alcohol or drugs as a way to cope ________ difficulty controlling drinking/drugging ________ eating problems ________ worryinwwA^RNso{^RkZRg9RNsJR^o{o{RkZkZg9VcRo{RZco{Nsco{ZRg9VRo{RcZZVRg9ZRNsVo{^RRVVo{VVo{Nso{Rwcc^NsRo{  Wwwwwwwso{wwwwsww ZVNso{kZo{NskZkZVo{c^^^^kZZco{V cg9o{Ns^NsNs^o{NskZkZ    ]swwwswwwwwwwsw<^JRVg9RNsVRRRRR^VVc^Rc^RkZVcR~~~~~RR^R^ZZkZcZcJRZRg9Zcw? wwwswwg,~~~~Z~~~RZg9R^R^Z^ZZ^VNsZkZ^Rg9kZcZcJRo{cRg9Zcw      -ZJRc^ckZ^RR^kZR^cc   # g9ZVVg9^ZcV^s% g9Vg9cZRZc^VZg9 1kZZcVZZVc^VNsRsRcg9JR ?Zcg9Rcg9ZVZcsZNsVg9c^cVV^VZ^Ns ! kZZNsZo{NscZg9 %sZ^^g9Z^RkZVV/Zg9Vo{NsJRc^VZcZsJRo{g9 =cZsNsVkZZ^^Z VZcV^^VZRc^V E VZcZVZ^o{o{Nso{kZo{Z g9cg9ZVNs^Zg9cVo{ Cg9Vco{VZcsZVVo{NskZZNscg9^V^RVNsZZ1 NsVNs^kZZJRkZg9ZcZRsVZ 5NsVNs^g9VZg9R^cg9Vg9ZVVZ ' cZsRg9sZ^ZsJRo{g9 -^VsZ^ZsZZVNso{VZg9' NsZo{VVZ^NsNs^RZ 9sZZVZg9RNsZVg9ZVVo{^VZ^Ns ;NsV^NsVZscZVZZg9ccZNsg9VcZg9 7NsV^NsZZ^Ro{ZZRZZ^Rcg9s) kZZ^cZg9Nso{g9VJRg9g9 U#cZs^ZZo{Zg9ZVNsVg9^^co{VcsNskZZRkZg9cRccZZ^g9 7g9ZcVNsg9Z^R^Z^Vg9^Zs^VZ ?Zo{Vccg9^Vsg9c^Zg9VRNsRsRcg9^V ) ZVcg9NsNsRsRcg9V^[&g9VsRo{ZVZg9V^g9^^Z^Nsg9cZ^g9VNsZ^VZRsRcZRVcg9V -^Ro{ZZ^Ns^ZkZ^RVNsZZ 5Vg9^Vg9ZV^NsZo{s^ZRZVVs /ZVVo{o{Nsc^RkZ^Zc^VZg9    NsZo{Zs   +RZo{RZVZs^Zo{RJRg9g9 G^RVNsZo{g9Vo{V^Zo{VZg9V^^ZNsco{NsRsZVg9-kZZNsZo{ZZ^g9g9Ns^Zo{s                 a jbjb111$0[[ $.&&&&&i&FFFF$G,,KQGQGQGQGQGQGQGQGJJJJJJJ,MROJo&QGQGQGQGQGJJ&&QGQGbKJJJQG&QG&QGJJ-&$Q&&&&&QGJJJ&&JEG FgG^JJxK0KJlPJlPJJ&,, 9 ,,9Stressor Checklist Name: _____________________________________ Date: _________________ Rate the level of distress you are currently experiencing by circling the appropriate number: No Distress 0 1 2 3 4 5 6 7 8 9 10 Extreme Distress Please read the following checklist and check once the items of concern to you. Check twice those items which are of most concern to you. Personal/Interpersonal: _______ values conflict _______ sexual concerns _______ long-distance relationship _______ anxious about meeting new people _______ lack of friends _______ too much social life _______ over reliance on others _______ not feeling good about appearance _______ wondering if I will find a suitable partner _______ significant other relationship problems _______ feeling lonely and isolated _______ feelings easily hurt by others ________ not trusting others _______ getting into arguments ________ fear being rejected _______ too easily led by other people _______ feeling that nobody understands _______ feeling discriminated against ________ lack assertiveness _______ not comfortable with current cultural surroundings ________ trouble socializing with others ________ difficulty getting over a relationship ________ abusive relationship ________ victim of past physical/sexual/verbal/emotional abuse ________ criminal/legal problems ________ excessive credit card debt ________ other financial concerns Family: ______ family death or illness ______ problems with parents/children/relatives _______ lack of family support Emotional: _______ feeling nervous/anxious _______ unhappy much of the time _______ feeling tired _______ emotional ups and downs ________ being impulsive _______ feeling as though life is not worth living _______ thoughts of harming others _______ thoughts of suicide ________ injuring self or thoughts of doing so ________ flashbacks of past trauma ________ recurrent thoughts, impulses or images that are intrusive or unwanted ________ worrying about unimportant things _______ feeling uncomfortable when alone ________ feeling that others are talking about me _______ difficulty controlling anger ________ feeling agitated/irritable Health/Physical: ________ use of alcohol or drugs as a way to cope ________ difficulty controlling drinking/drugging ________ eating problems ________ worryin