• M.A.S.T. Assessment Form

  • Client and Assessment Information

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Substance Use History and Frequency

  • Which substances have you used in the past?*
  • Which substances are you currently using?*

  • Impact, Consequences, and Related Problems

  • Legal, Employment, and Social Issues

  • Have you had any legal problems related to substance use?*
  • Has substance use caused employment problems, missed work, or job loss?*

  • Mental Health and Prior Treatment

  • Which mental health symptoms have you experienced?*
  • Have you had any thoughts of harming yourself or others?*

  • Readiness to Change and Treatment Goals

  • Do you feel you need help to make these changes?*
  • Are you willing to participate in treatment or support services?*

  • Additional MAST Screening Questions

    Please replace the word drink with substances if that is why you are doing this assessment
  • Have you ever felt you should cut down on your drinking?*
  • Have people annoyed you by criticizing your drinking?*
  • Have you ever blacked out from drinking?*
  • Have you ever driven or operated machinery after drinking?*
  • Do you feel you are a normal drinker? ("normal" - drink as much or less than most other people)*
  • Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening?*
  • Does any near relative or close friend ever worry or complain about your drinking?*
  • Can you stop drinking without difficulty after one or two drinks?*
  • Do you ever feel guilty about your drinking?*
  • Have you ever attended a meeting of Alcoholics Anonymous (AA)?*
  • Have you ever gotten into physical fights when drinking?*
  • Has drinking ever created problems between you and a near relative or close friend?*
  • Has any family member or close friend gone to anyone for help about your drinking?*
  • Have you ever lost friends because of your drinking?*
  • Have you ever gotten into trouble at work because of drinking?*
  • Have you ever lost a job because of drinking?*
  • Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?*
  • Do you drink before noon fairly often?*
  • Have you ever been told you have liver trouble such as cirrhosis?*
  • After heavy drinking have you ever had delirium tremens (D.T.'s), severe shaking, visual or auditory (hearing) hallucinations?*
  • Have you ever gone to anyone for help about your drinking?*
  • Have you ever been hospitalized because of drinking?*
  • Has your drinking ever resulted in your being hospitalized in a psychiatric ward?*
  • Have you ever gone to any doctor, social worker, clergyman or mental health clinic for help with any emotional problem in which drinking was part of the problem?*
  • Have you been arrested more than once for driving under the influence of alcohol?*
  • Have you ever been arrested, even for a few hours because of other behavior while drinking?*

  • SCORING 0 - 2 No apparent problem 3 - 5 Early or middle problem drinker 6 or more Problem drinker

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Disclosure of Information

  • I understand that if I am court-ordered or have been referred by a court, probation/parole agent, attorney, employer, or other authorized agency, Pam's Place Counseling Center may disclose information related to my participation as permitted by law and/or as authorized by my signed Release of Information. Information that may be disclosed includes, but is not limited to, MAST form, enrollment status, attendance, participation, compliance, progress, completion status, assessment results (when authorized), recommendations, and discharge status. I understand that these disclosures are made for the purpose of reporting my compliance with program requirements and may be provided to the court, probation/parole, attorneys, referral sources, or other individuals or agencies authorized by law.

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