Cleaning household items or other objects excessively ☐ Doing other things to prevent or remove contact with contaminants

Checking

☐ Checking that you did not/will not harm others ☐ Checking that you did not/will not harm yourself ☐ Checking that nothing terrible happened ☐ Checking that you did not make a mistake ☐ Checking some parts of your physical condition or body

Repeating

☐ Rereading or rewriting ☐ Repeating routine activities (examples: going in or out doors, getting up or down from chairs) ☐ Repeating body movements (example: tapping, touching, blinking) ☐ Repeating activities in “multiples” (examples: doing a task three times because three is a “good,” “right,” “safe” number)

Mental Compulsions

☐ Mental review of events to prevent harm (to oneself others, to prevent terrible consequences) ☐ Praying to prevent harm (to oneself others, to prevent terrible consequences) ☐ Counting while performing a task to end on a “good,” “right,” or “safe” number ☐ “Cancelling” or “Undoing” (example: replacing a “bad” word with a “good” word to cancel it out)

Other Compulsions

☐ Putting things in order or arranging things until it “feels right” ☐ Telling asking or confessing to get reassurance ☐ Avoiding situations that might trigger your obsessions

3) Any Obsessions/Compulsions not noted above:

4) What have you been struggling with most lately and how can we help?

5) Share a good meme: