Take the Personal Assessment

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Ask for:
Steve Nadauld,
Cheryl Bennett, or
Barbara Davis

OBHIC

NATSAP

Personal Assessment

» Guardian or Sponsor

Guardian or Sponsor










How urgent is your need to get help for your participant?

Adults must be willing to commit to treatment... Is your adult willing to commit to treatment?
   
Are there any legal or court issues pending?
   
Do you have access to the resources needed to pay for treatment?
   
If you chose to place your young adult in treatment, would you need to borrow funds?
   

» Participant

Participant

This assessment needs to be filled out by the participant. Participants are generally between the ages of 18-25.







Instructions

Looking back over the last week, including today, help us understand how you have been feeling. Read each item carefully and click the circle under the category which best describes your current condition. For this questionnaire, work is defined as employment, school, housework, volunteer work, and so forth.

1. I get along well with others.
2. I tire quickly.
3. I feel no interest in things.
4. I feel stressed at work/school.
5. I blame myself for things.
6. I feel irritated.
7. I feel unhappy in my marriage/significant relationship.
8. I have thoughts of ending my life.
9. I feel weak.
10. I feel fearful.
11. After heavy drinking, I need a drink the next morning to get going. (If you do not drink, mark 'Never')
12. I find my work/school satisfying.
13. I am a happy person.
14. I work/study too much.
15. I feel worthless.
16. I am concerned about family troubles.
17. I have an unfulfilling sex life.
18. I feel lonely.
19. I have frequent arguments.
20. I feel loved and wanted.
21. I enjoy my spare time.
22. I have difficulty concentrating.
23. I feel hopeless about the future.
24. I like myself.
25. Disturbing thoughts come into my mind that I cannot get rid of.
26. I feel annoyed by people who criticize my drinking (or drug use). (If not applicable, mark 'Never')
27. I have an upset stomach.
28. I am not working/studying as well as I used to.
29. My heart pounds too much.
30. I have trouble getting along with friends and close acquaintances.
31. I am satisfied with my life.
32. I have trouble at work/school because of drinking or drug use. (If not applicable, mark 'Never')
33. I feel that something bad is going to happen.
34. I have sore muscles.
35. I feel afraid of open spaces, of driving, or being on buses, subways, and so forth.
36. I feel nervous.
37. I feel my love relationships are full and complete.
38. I feel that I am not doing well at work/school.
39. I have too many disagreements at work/school.
40. I feel something is wrong with my mind.
41. I have trouble staying asleep or falling asleep.
42. I feel blue.
43. I am satisfied with my relationships with others.
44. I feel angry enough at work/school to do something I might regret.
45. I have headaches.
Are you ready to commit to treatment?
   

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