During the last week, how many days have I used alcohol or drugs:
*
0
1
2
3
4
5
6
7
Each time I used alcohol or drugs during this week I used (how much / how many)
*
This volume is
*
Same
More
Less
The last time I used was
*
0
1
2
3
4
5
6
7
8
9
10
Radio Group
*
Days
Weeks
Months
I have taken medications as prescribed this week:
*
Yes
No
I have met, or am scheduled to meet, with the therapist this week:
*
Yes
No
I have attended, or plan to attend, group meetings at least twice this week:
*
Yes
No
I have journaled how many days this week:
*
0
1
2
3
4
5
6
7
I have exercised how many times this week:
*
0
1
2
3
4
5
6
7
How many hours of sleep did I get on average each night:
*
1
2
3
4
5
6
7
8
9
10
10
Has the quality of your diet
*
improved
stayed the same
declined
Mental Status (Low to High; 0=None 10=A Lot)
Overall CRAVING in the last week:
*
0
1
2
3
4
5
6
7
8
9
10
My current MENTAL STATUS (meaning anxiety, moodiness, depression are low)
*
0
1
2
3
4
5
6
7
8
9
10
My current RELATIONSHIP with family/significant other is
*
0
1
2
3
4
5
6
7
8
9
10
My current level of FUNCTIONING (accomplishments in spite of feelings) is
*
0
1
2
3
4
5
6
7
8
9
10
My current level of COPING emotionally is
*
0
1
2
3
4
5
6
7
8
9
10
*** (USE VOCABULARY) Describe one current situation or problem where you have/are impleting ATS tools to assist you. What is working well or what is causing problems for you? Can YOU do anything differently?
*
Please verify that you are a real person by answering the question: 2 + 2 = ?
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