This Form cannot be submitted until the missing
fields (labelled below in red) have been filled in
Please note that all fields followed by an asterisk must be filled in. First Name*
Substance or activity I am having difficulty with:
Using has interfered with reaching my potential.
I have thinking patterns that trigger the desire to use.
My using behavior feels automatic.
I am clear about what triggers my using behavior.
Trigger A and Response B can become conditioned ways of being.
The frequency of my use is:
When I use I intend to go all out.
I use to manage stress or anxiety.
Due to my use I have experienced blackout/s.
A family member or friend has expressed concern about my use.
I use to manage depression or uncomfortable feelings.
I have missed work as a result of my use.
I have had difficulty functioning at work due to my use.
I have attended work under the influence in the past year.
My use has caused me to miss out on activities I enjoy.
I have been secretive about my use.
My use has resulted in behavior that embarrasses me.
My use has resulted in behavior that embarrasses my spouse.
I have tried to manage or control my use but been unable to.
I find it hard to stop using once I begin.
I have needed to spend time recovering from the effects of my use in the past year.
I use more then I intend to.
I have had strong cravings for using.
My use has resulted in unmet obligations to others.
My use has resulted in unmet obligations to myself.
I have experienced physical withdrawal symptoms when not using.
My use has put me in physically dangerous situations.
My use has resulted in criminal charges.
I use in the morning before my day begins.
My tolerance for using has increased.
I have had times when I didn't feel like using but did anyway.
I continue to use despite evidence that my health and general well-being are being negatively impacted.
Filling out this form made me think about my using.
I am in charge of my thoughts, feelings and behaviors
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