Please read this carefully before starting. You will need to allow more than one sitting to complete this. Remember that the purpose of this is to examine all of the affects of your substance use WITHOUT denial.
Have you ever had a blackout? A blackout usually occurs after consuming alcohol and is a period of activity (driving, talking, meeting people) that you do not recall, someone else has to tell you.
If you have had a blackout, give one specific example.
What were your feelings when you realized you had a blackout?
What are your feelings about this now?
While you were using alcohol or drugs, yourbehavior tends to become inappropriate or destructive (Assault, drinking and driving, verbal abuse, destruction of property)
List two specific examples of how you have been destructive when using alcohol or drugs.
What were your feelings then, once you sobered up?
What are you feelings now?
Family and friends may have complained about your drinking or using drugs. Children may not have said anything but were affected.
Give one specific example of how your substance use has affected a spouse/girlfriend, parent, etc. Include your feelings then and now.
Give one specific example of how your substance use has affected your children. (Think hard before you answer “never” to this). Include your feelings then and now.
Describe a specific incident in which you were affected, as a child, by someone else’s drug/alcohol use? Include your feelings then and now.
Work is negatively affected by substance use. (Coming in hungover, not working as fast as hard or as well, lack of motivation, arguments with supervisor or coworkers, missing time from work).
List one specific example of how substance use affected your work performance.
What were the consequences of this?
Are you under-employed – defined as in a job below your abilities?
If you are self-employed, is this because you have a hard time following your employers’ rules, getting there on time, etc.
The use of alcohol and drugs often stops your emotional development and is many times used to cope with feelings. In other words, when you start using drugs/alcohol you stop maturing emotionally. An emotionally immature person throws temper tantrums, has little/no impulse control, has no patience, requires immediate gratification, etc. An emotionally mature person handles their temper well, expresses feelings (other than anger and depression), is honest, etc.
Did the use of substances stop your emotional development? Why or Why not?
Give a specific example of when you used substances to cope with or express feelings?
What legal charges have you had in your whole life? (Remember to include Drunk in Public, DUI, Assault, Larceny, Destruction of Property, Possession, etc)
What is your current charge?
How many of these charges were alcohol or drug related? Remember to include those committed under-the-influence, while you were recovering from the effects of substances, or directly related to obtaining the substance.
Substance Use: We ask you to place your substance use in a category – use, abuse or dependence. The following will walk you through that process. Remember that you can meet the criteria for abuse for one substance (ex. – alcohol) but dependence for another (ex – cocaine)
Name all of the mood altering substances (include alcohol) that you have used more than twice in your life.
Did you have tolerance to the substance? YES NO Did you have withdrawal effects from the substance? YES NO
Did you ever attempt to cut down or fail to stop YES NOthe use of the substance?