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Beck Anxiety Inventory
Below is a list of common symptoms of anxiety. Please carefully read each item on the list. Indicate how much you have bee bothered by that symptom during the past month, including today, by circling the number in the corresponding space in column next to each symptom
Name
First
Last
Email
Phone
Questionnaire - Select one option that is the best fit.
Choices:
None at all
Mild - Doesn't bother you much
Moderate - Not pleasant at times
Severe - Bothers you a lot
1) Numbness or Tingling
None
Mild
Moderate
Severe
2) Feeling hot
None
Mild
Moderate
Severe
3) Wobbliness in legs
None
Mild
Moderate
Severe
4) Unable to relax
None
Mild
Moderate
Severe
5) Fear of worst happening
None
Mild
Moderate
Severe
6) Dizzy or lightheaded
None
Mild
Moderate
Severe
7) Heart pounding/racing
None
Mild
Moderate
Severe
8) Unsteady
None
Mild
Moderate
Severe
9) Terrified or afraid
None
Mild
Moderate
Severe
10) Nervous
None
Mild
Moderate
Severe
11) Feeling of choking
None
Mild
Moderate
Severe
12) Hands trembling
None
Mild
Moderate
Severe
13) Shaky / Unsteady
None
Mild
Moderate
Severe
14) Fear of losing control
None
Mild
Moderate
Severe
15) Difficulty in breathing
None
Mild
Moderate
Severe
16) Fear of dying
None
Mild
Moderate
Severe
17) Scared
None
Mild
Moderate
Severe
18) Indigestion
None
Mild
Moderate
Severe
19) Faint / Lightheaded
None
Mild
Moderate
Severe
20) Face flushed
None
Mild
Moderate
Severe
21) Hot / cold sweats
None
Mild
Moderate
Severe
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Schedule an Appointment
Location:
401 N Michigan Ave
Suite 1200
Chicago
Phone
Call: 312-822-3436
Name
Email
Phone
Date
Time
Primary Concern
Send Request
HIPAA Authorization V2
I have been given and read the Agreement (Therapist-Patient Agreement with Chicago Psychological (Dated January 1, 2010) and I agree to its terms.
Printed Name of the Patient
*
First
Last
Signed Date:
*
Date Format: MM slash DD slash YYYY
Signature of the Adult if Patient
_______________
Date Signed
_______________
Signature of Minor Client (if age 12-17):
_______________
Date Signed
_______________
Signature of Legal Guardian for Minor Client:
_______________
Date Signed
_______________
Consent
I acknowledge the receipt of HIPAA Notice.
I acknowledge that I have received the HIPAA Notice Form (Notice of Chicago Psychological Policies and Practices to Protect the Privacy of Your Health Information).
Printed Name of the Client
*
Full Name
Signed Date:
Date Format: MM slash DD slash YYYY
Signature of the Adult if Client
_______________
Date Signed
_______________
Signature of Minor Client (if age 12-17):
_______________
Date Signed
_______________
Signature of Legal Guardian for Minor Client:
_______________
Date Signed
_______________
Send me the PDF to be signed to this E-mail address
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