Client ID#
______________
Date: _____/_____/_____
Assessment Point: ______________ |
| THE FOLLOWING STATEMENTS
MAY PLAY A PART IN MAKING A DECISION ABOUT USING ALCOHOL (AND
DRUGS). WE WOULD LIKE TO KNOW HOW IMPORTANT EACH STATEMENT IS TO YOU
AT THE PRESENT TIME IN RELATION TO MAKING A DECISION TO EACH
STATEMENT ON THE FOLLOWING 5 POINTS: |
1 = Not important at all
2 = Slightly important
3 = Moderately important
4 = Very important
5 = Extremely important |
| PLEASE READ EACH STATEMENT
AND CIRCLE THE NUMBER ON THE RIGHT TO INDICATE HOW YOU RATE ITS
LEVEL OF IMPORTANCE AS IT RELATES TO YOUR MAKING A DECISION ABOUT
WHETHER TO DRINK (OR USE DRUGS) AT THE PRESENT TIME. |
| How
important is this to me? |
Importance
in making a decision about drinking: |
|
| |
|
Not At All |
Slightly |
Moderately |
Very |
Extremely |
|
| 1. |
My drinking (drug use) causes problems
with others. |
1 |
2 |
3 |
4 |
5 |
| 2. |
I like myself better when I am drinking
(using drugs). |
1 |
2 |
3 |
4 |
5 |
| 3. |
Because I continue to drink (use drugs)
some people think I lack the character to quit. |
1 |
2 |
3 |
4 |
5 |
| 4. |
Drinking (drug use) helps me deal with
problems. |
1 |
2 |
3 |
4 |
5 |
| 5. |
Having to lie to others about my
drinking (drug use) bothers me. |
1 |
2 |
3 |
4 |
5 |
| 6. |
Some people try to avoid me when I
drink (use drugs). |
1 |
2 |
3 |
4 |
5 |
| 7. |
Drinking (drug use) helps me to have
fun and socialize. |
1 |
2 |
3 |
4 |
5 |
| 8. |
Drinking (drug use) interferes with my
functioning at home or/and at work. |
1 |
2 |
3 |
4 |
5 |
| 9. |
Drinking (drug use) makes me more of a
fun person. |
1 |
2 |
3 |
4 |
5 |
| 10. |
Some people close to me are
disappointed in me because of my drinking (drug use). |
1 |
2 |
3 |
4 |
5 |
| 11. |
Drinking (drug use) helps me to loosen
up and express myself. |
1 |
2 |
3 |
4 |
5 |
| 12. |
I seem to get myself into trouble when
drinking (using drugs). |
1 |
2 |
3 |
4 |
5 |
| 13. |
I could accidentally hurt someone
because of my drinking (drug use). |
1 |
2 |
3 |
4 |
5 |
| 14. |
Not drinking (using drugs) at a social
gathering would make me feel too different. |
1 |
2 |
3 |
4 |
5 |
| 15. |
I am losing the trust and respect of my
coworkers and/or spouse because of my drinking (drug use). |
1 |
2 |
3 |
4 |
5 |
| 16. |
My drinking (drug use) helps give me
energy and keeps me going. |
1 |
2 |
3 |
4 |
5 |
| 17. |
I am more sure of myself when I am
drinking (using drugs). |
1 |
2 |
3 |
4 |
5 |
| 18. |
I am setting a bad example for others
with my drinking (drug use). |
1 |
2 |
3 |
4 |
5 |
| 19. |
Without alcohol (illegal drugs), my
life would be dull and boring. |
1 |
2 |
3 |
4 |
5 |
| 20. |
People seem to like me better when I am
drinking (using drugs). |
1 |
2 |
3 |
4 |
5 |
Scoring:
Pros of drinking (drug use) are items: 2, 4, 7, 9, 11, 14, 16, 17,
19, 20.
Cons of drinking (drug use) are items: 1, 3, 5, 6, 8, 10, 12, 13,
15, 18.
To get the average number of pros endorsed, add up the total number
of points from the items and divide by 10. Example: Pros of drinking
(drug use) = Sum of items (2+4+7+9+11+14+16+17+19+20) divided by 10.
To get the average number of cons endorsed, add up the total number
of points from the items and divide by 10. Example: Cons of drinking
(drug use) = Sum of items (1+3+5+6+8+10+12+13+15+18) divided by 10. |
