Confidential Assesment Form at The Cabin Chiang Mai

First Name / Last Name*

*

Phone*

Best Time to Call*

What country are you from?*

Who are you contacting us for?*

Please provide their name **

Where did you hear about us? *

How many drugs are you or the addict addicted to? *

WHAT IS THE PRIMARY DRUG ?

Method of intake:

How much is being used daily?

For how long?

WHAT IS THE PRIMARY DRUG ?

Method of intake:

How much is being used daily?

For how long?

WHAT IS THE SECOND DRUG ?

Method of intake:

How much is being used daily?

For how long?

How old are you or the addict?

At what age did use begin?

What have been some of the problems that the addiction has caused?

What is the family attitude toward the addiction?

Do you or the addiction admit that there is an addiction?

Do you or the addict want help?

Depression, Anxiety and Stress Scale

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

1. I found it hard to wind down

0
1
2
3

2. I was aware of dryness in my mouth

0
1
2
3

3. I couldn't seem to experience any positive feelings at all

0
1
2
3

4. I experienced breathing difficulty (eg. excessively rapid breathing)

0
1
2
3

5. I found it difficult to work up the initiative to do things

0
1
2
3

6. I tended to over-react to situations

0
1
2
3

7. I experienced trembling (eg. in the hands)

0
1
2
3

8. I felt that I was using a lot of nervous energy

0
1
2
3

9. I was worried about situations in which I might panic and make a fool of myself

0
1
2
3

10. I felt that I had nothing to look forward to

0
1
2
3

11. I found myself getting agitated

0
1
2
3

12. I found it difficult to relax

0
1
2
3

13. I felt down-hearted and blue

0
1
2
3

14. I was intolerant of anything that kept me from getting on with what I was doing

0
1
2
3

15. I felt I was close to panic

0
1
2
3

16. I was unable to become enthusiastic about anything

0
1
2
3

17. I felt I wasn't worth much as a person

0
1
2
3

18. I felt that I was rather touchy

0
1
2
3

19. I was aware of the action of my heart in the absence of physical exertion (eg. sense of heart rate increase, heart missing a beat)

0
1
2
3

20. I felt scared without any good reason

0
1
2
3

21. I felt that life was meaningless

0
1
2
3

Drug Taking Confidence Questionnaire

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.

I would be able to resist the urge to use alcohol and/or drugs:

1. If I were angry at the way things had turned out

2. If I had trouble sleeping

3. If I remembered something good that had happened

4. If I wanted to find out whether I could use alcohol and/or drugs occasionally without getting hooked

5. If I unexpectedly found some alcohol and/or drugs or happened to see something that reminded me of alcohol and/or drugs

6. If other people treated me unfairly or interfered with my plans

7. If I were out with friends and they kept suggesting we go somewhere and use alcohol and/or drugs

8. If I wanted to celebrate with a friend

Please let us know any other information or questions you may have

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Assessment Form

Confidential Online Assessment

Depression, Anxiety and Stress Scale

Drug Taking Confidence Questionnaire