PRELIMINARY SELF-ASSESSMENT-Part B

Please note that all fields followed by an asterisk must be filled in.

First Name*

E-Mail Address*

City*

Best telephone number*

I have life goals that are important to me.*

My behavior has had a negative impact on my ability to reach my potential. *

I have thinking patterns that trigger the desire to use.*

My using behavior feels automatic.*

My using behavior feels outside of my control.*

I am clear about what triggers my using behavior.*

Trigger A and Response B can become an automatic conditioned way of being.*

I am able to interrupt automatic responses to triggers.*

Additional information you wish to provide.

Please enter the word that you see below.