Section I: Qualities of a Parent or Sponsor
Have you had experience with substance abusers?
Have you read literature on substance abuse?
Are you familiar with the psychological effects of the common substances of abuse?
Are you familiar with the physical effects of the common substances of abuse?
Are you familiar with the social effects of the common substances of abuse?
Are you familiar with the most common forms of treatment for substance abuse?
Have you discussed drug abuse with your children?
Have you condemned drug abuse?
Have you expressed your dislike for your children's friends who you know or suspect are using drugs?
Have you told your family that drug use will not be accepted in your home?
Have you asked for their help in keeping drugs out of the home?
Have you been careful not to use drugs in front of your children?
Have you been careful not to let your children see you high or drunk?
Have you told your children that you love them?
Do you set time aside to listen and discuss problems with your children?
Do you spend time together as a family?
Do you spend time with your spouse?
Do you listen to your spouses problems?
Are you supportive of your spouse's interests and problems?
Do they know that you care for them?
Do you provide for your family?
Do you make sacrifices for your children?
Do you make sacrifices for your spouse?
Section II: Qualities of the Home
Do people in the home have trouble getting along?
Are there arguments in the home between parents?
Are there arguments in the home between other family members?
Is there negative tension in the home?
Is there physical violence in the home?
Are there people in the family who use drugs?
Are there family members who sell drugs?
Are there family members who have drug abuser friends calling or coming by the house?
Is there verbal abuse and cursing in the home?
Are there healthy adults in the house who are not working?
Have children in the family dropped out of school?
Have family members been allowed to get high in the house?
Have family members been allowed to sell or purchase drugs in the house?
Have minors been out past 9:00 pm without calling or an adult knowing where they are?
Are minors allowed to associate with whoever they want?
Are children made to feel uncomfortable at home?
Are adults in the family made to feel uncomfortable at home?
Is there disrespect among family members?
Is there little support for each other among family members?
Are relationships between family members weak?
Section III: General Indicators - For Subject
Section IV: Qualities of Mental Health - For Subject
Problems Losing Weight
Problems Getting to Sleep
Has Mood Swings
Has Sad Moods
Has a Quick Temper
Laugh a Great Deal
Cry a Great Deal
Talks about Suicide
Is Verbally Threatening to Others
Disrespectful towards Authority
Thinks Everyone is Against Him/Her
Believes Things That Are Not True
Been Treated for a Mental Problem
Has a Bad Attitude about Life
Not Care About School or Work
Has Trouble Remembering Things
Problems with Memory
Has Shakes and Tremors
See Things that are Not There
Talks to self
Talks to People that No one Else Sees
Is Very Sensitive or Easily Offended
Is Fidgety or Restless
Is Slow and Listless
Section V: Qualities of Personal Relationship - For Subject
Is Detached and Withdrawn
Comes Home Late from Work or School
Comes Home After 10:00 PM
Hangs Out with Friends Until Very Late
Oversleeps in the Morning
Is Late for School or Work
Is Absent from School or Work
Has Disagreements with Teachers and Supervisors
Has Difficulty Maintaining a Job, staying in school
Comes Home Late on Payday
Comes Home Intoxicated
Spends Large Amounts from Paycheck
Does Not Bring Paycheck Home
Associates with Undesirable Friends
Has Relationship with Another Man Or Woman
Is Verbally Abusive
Is Physically Abusive
Is Sexually Inactive with Spouse
Friends Call or Come by Late at Night Without Being Introduced
Does Not Come Home on Pay day
Section VI: Qualities of Addictive Behavior - For Subject
Is Unfriendly Toward Others
Sweats a Great Deal When Talking
Seems Manipulated by Others
Is Sexually Seductive
Attempts to Take Control
Is Evasive When Asked Direct Questions about Drugs
Is Suspicious of Others
Rarely Makes Sense
Has unclear Thoughts
Exercises Poor Judgment
Rarely Gives Clear Answers to Questions
Has Short Attention Span
Is Fearful or Scared
Is Easily Influenced by Friends
Has Lost Interest in personal Appearance
Has Lost Interest in their Work or School
Talks about Drugs
Has History of Using Drugs
Believes he/she can Associate with Addicts and Not Use Drugs
Believes he/she can Use Drugs and can Stop when he/she Wants
Claims to want to use drugs to help:
Overcome Emotional Pain
Overcome Physical Pain
the Way he/she Looks
the Way he/shes treated by others
work or school environment
Has Lost Interest in:
Lies or is Evasive about Outside Activities
Steals Money or Misuses Money
Neglects Responsibilities Toward:
Brothers or Sisters
Are Other Addicted Persons:
Living with Subject?
Working with Subject?
Going to School with Subject?