Assessment of substance use disorder
Please fill the Form below. Answer all the Questions. Don't 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
Your Name/Nick Name:
Your E-Mail
example@example.com
Date of filling the Form
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Types of substances used during the last 1 Year
Alcohol
Nicotine
Opiates
Hallucinogens
Cannabis
Other
How long you had been using Each of the above
Date and time of last use(For each Type)
When did you start to feel this as a problem
Do you feel the need to take more quantity of substance to get the same high as you felt before (Yes/No)
Please Select
Yes
No
Timing of Drug use for each type(Morning, Evening, Bedtime, At work, etc.
Tick the most appropriate option
Rows
Never
Rarely
Sometimes
Most times
Always
How often you felt irritable and restless if you fail to get the substance
I plan my routine, Journey, Visits .etc. According to the availability/ Chance to use substance.
With whom you use substance more often
Friends
Colleagues
family members
Relatives
Strangers
Alone
Have you undergone therapy earlier for substance use?
Please Select
Yes
No
Have you abstained from using substance earlier. If yes please specify duration and when.
In case of relapse (started using again), what prompted you for the relapse?
On a scale of 0 to 10, how confident you are about making the change?
On a scale of 0 to 10, how intense does the substance abuse affect your day-to-day activities, work etc.
On a scale of 0 to 10, how intensely you are ready to work towards change?
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.
Rows
Never
Rarely
Sometimes
Most times
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
Why did you prefer to come for therapy?
What are the benefits and positive effects that you experience on using it.
What may be the possible physical, psychological, family, social and work place issues that you are likely to face/already facing due to the use of substance
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