Alcoholism and addiction questionnaire

Alcoholism / addiction is an illness, which centres in the mind and affects the physical body as well. It can be a very confusing condition for the sufferer and their family, who often are not sure whether alcohol and / or drugs are the problem. By completing and submitting our questionnaire, we can help you figure out if you have a problem. We can also talk you through treatment options at Trust The Process Counselling. All enquiries are confidential and we do not share your information with any other organisation or individual.

What substances do you use on a regular basis?

	Alcohol		Amphetamines
	Antidepressants		Benzodiazepines (eg valium, temazepam, lorazepam, diazepam etc)
	Cannabis		Cocaine (powder)
	Codeine / DF118s		Crack cocaine
	Crystal meth		Ecstasy
	Hallucinogens		Ketamine
	MDMA		Opiates (Heroin / Methadone)
	Prescribed drugs		Solvents and Inhalants
	Other

How often do you use at least one of these substances?

	Daily		Most days
	A couple of times a week		On weekends
	A few times a month		I use a lot then don’t use for a while
	On special occasions		Rarely
	Never, but I think about drinking or using a lot		Other

Do you believe you have a problem with alcohol or drugs?

	Yes		No
	Not sure

What are the major reasons that you use or drink? (you can tick more than one option)

	To have fun		To escape life's problems for a bit
	To join in with friends or a partner		To experience the high of the drug or drink
	To get away from negative feelings		To ease a sense of irritability
	To calm myself down		To help me stay up later
	To help me get to sleep		To switch off the mind
	To enhance my life		To experience something out of the ordinary
	To get away from boredom		To stop the self-critical voice inside of me
	To enhance a good mood		To change an unpleasant mood
	To celebrate happy events		To cope with unpleasant events
	To feel more confident		To be able to socialise more effectively
	Other

Have you ever experienced any of the following as a direct result of your drink or drug use? (you can tick more than one box)

	Drink driving / drug driving		Loss of driving licence
	Loss of job		Hospitalisation
	Accidents		Relationship breakdown
	Loss of a friendship		Financial problems
	Violence towards you		Violence you have initiated
	Feeling embarrassed about things you have said or done		Involvement in petty criminal activity
	Involvement in serious criminal activity		Moving areas to 'start afresh' but then soon things were out of control again
	Having sex with someone you regret sleeping with		Having unprotected sex
	Contracting an STD		Telling lies to cover up drinking or drug taking
	Losing belongings eg your wallet, jacket or keys etc		Other

Have you ever had any of the following symptoms / conditions as a direct result of your drink or drug use? (you can tick more than one box)

	Depressive symptoms (low mood)		Sleeplessness
	Sweating		Tremors (the shakes)
	Fitting		Vomiting
	Persistent suicidal thoughts or attempted suicide		Blackouts (memory loss as a result of drinking / drug-taking)
	Extreme mood swings		Panic attacks
	Exhaustion		Paranoia
	Appetite gain		Appetite loss
	Severe weight gain		Severe weight loss
	Racing mind		Hyperactivity
	Delusional thoughts		Hallucinations
	Liver complaints		Stomach complaints
	Heart problems		Other

Which of the following statements apply to you? (you can tick more than one box)

	My friends / family have commented that I'm drinking too much or using too many drugs		I've taken days off work because I’ve been hungover or on a come down
	I used to be able to take it or leave it but now I can't seem to stop		My life would be boring without alcohol or drugs
	I'd like to be able to stop but what would my friends think?		I would stop but my partner does it
	I’ve tried to stop on my own before and it was too hard		Life's too short not to have fun
	I could easily stop if I wanted to, I just I don't want to		I have tried to cut down in the past
	I have tried substituting drinks / drugs to control my intake (eg drinking wine instead of spirits or smoking cannabis instead of taking coke)		I have worries about what might happen if I don't stop drinking or taking drugs
	I find myself going out with the same people and doing the same things, everything revolving around drink and / or drugs		I have had arguments with my partner about my drinking and / or drug use
	I regularly drink to get drunk or take drugs to get really out of it		I drink or take drugs to be the 'real me'
	l like the feeling of being in control that drink or drugs gives to me		I know I've got a problem, I just don't know how to stop
	If only everyone would stop going on at me about drink or drugs, then I'd be ok		I drink or take drugs because some people in my life deliberately annoy me
	I can't have a laugh without drink or drugs		Drink and / or drugs relax me – I feel irritable without them
	I've got a nagging feeling I might be addicted but would rather ignore it		I want to do more with my life but feel that drink or drugs is holding me back
	If you had the problems I had, then you’d drink or take drugs like I do		I sometimes lie about how much I’ve used or drank to my family or friends

In general, when is the most convenient time to contact you?

	Anytime		Mornings (9am - 12pm)
	Afternoons (12pm - 5pm)		Evenings (5pm - 10pm)

How did you hear about Trust The Process?

	Google		Yahoo
	MSN		Other search engine
	Newspaper / magazine / television / radio		Trust The Process Counselling newsletter
	Email from Trust The Process Counselling		Telephone directory
	Word of mouth		Other