Behavioural Addiction Assessment Form.

Please fill the Form below. Answer all the Questions. Dont think too much. Fill it With The Answer that comes first to your mind. Your response will be kept confidential. It will be used only for treatment and research purpose. Copyright © 2021 psyclinic

Name/Nick name*

Email

example@example.com

Date of Filling The Form.*

Date

Type of Undesirable/Addictive/Compulsive Behaviour.*

How long you had been indulging in this behaviour.*

Approximate time/Money spent for the same at beginning*

Approximate time/Money spent for the same now*

Date and time of last indulgence*

Have you undergone treatment/Therapy for the same earlier? (YES/NO)*

Details of attempts made to abstain from this behaviour earlier. (Specify duration of abstinence, reason for abstinence .etc.)*

Incidence of relapse(To continue again).(Specify reason).*

Do you had suicidal thoughts due to the impact of this behaviour? (Yes/No)*

Do you use any substance like alcohol, cannabis, opiates. nicotine etc. If yes specify the type of substance, quantity of intake and how often you use it.

According to you what made you to get addicted to this Behaviour. Please tick the most appropriate answer from the table below for each question.

Please evaluate honestly*

	Never	Rarely	Some times	Most tmes	Always
To get high and to have pleasant feeling:
For fun:
To forget my worries and bad mood:
To enjoy with friends:
Pressure from peer:
To avoid feeling left out:
To alleviate loneliness :
To alleviate stress at work:
Relationship issues:
Stress at home:
Lack of help/Social support:
Lack of self discipline:
Lack of awareness about implications/Consequences:
Being adventures:
With intension of self harm/Lack of self care:
Unemployment/excess leisure time

Feel free to answer the following:

Mention the impact of this undesirable behaviour on the following areas

1) Physical wellbeing(eg: Headache, nausea .etc)*

2) Psychological wellbeing( eg: increased stress, Anxiety, loneliness .etc.)*

3) Social and Family wellbeing( eg: Workplace/Family issues .etc.*

4) Spiritual/ Religious wellbeing( eg: Guilt, Shame .etc.*

5) On a scale of 0-10, how intense does it affect adversely your daily life activities/Job/Studies *

6) On a scale of 0-10, how confident you are about the prospect of changing the behaviour*

7) On a scale of 0-10, how motivated you are to change this behaviour*

8) On a scale of 0-10, how intensely you are ready to work towards the change.*

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