Assessment Form

This scale measures factors which are often present alongside substance use. Completing this scale allows us to measure your progress individually and informs practice.

Please read each statement and circle a number 0,1,2 or 3 to indicate how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

0: Did not apply to me at all
1: Applied to me to some degree, or some of the time
2: Applied to me to a considerable degree, or a good part of time
3: Applied to me very much, or most of the time

Listed below are a number of situations or events in which some people experience a drug use problem.

Imagine yourself as you are right now - in each of these situations. Indicate on the scale provided how confident you are that you will be able to resist the urge to use alcohol and/or drugs in that situation.

Circle 100 if you are 100% confident right now that you could resist the urge to use alcohol and/or drugs; 80 if you are 80% confident; 60 if you are 60% confident. If you are more unconfident than confident, circle 40 to indicate that you are only 40% confident that you could resist the urge to use alcohol and/or drugs; 20 for 20% confident; 0 if you have no confidence at all about that situation.