Relapse Self Assessment Questionnaire

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Call 888-755-3334 to speak with an intake specialist now or fill out the form below and we will call you.

*(denotes required field)

Name:*

E-Mail Address:*

1. Do you feel you have a lack of personal confidence to remain clean/sober or abstinent?*

Yes
No

2. Has anyone suggested that you may be in denial?*

Yes
No

3. Do you find yourself trying to convince yourself or others that you will never ever drink or use again?*

Yes
No

4. Do you start imposing recovery on other people?*

Yes
No

5. Do you become defensive when talking about your problem in recovery?*

Yes
No

6. Have compulsive behaviors appeared or have you adopted a non-structured lifestyle?*

Yes
No

7. Do you over-react or are impulsive behaviors beginning to appear?*

Yes
No

8. Are you experiencing periods of loneliness?*

Yes
No

9. Have you begun to focus on one certain area in your life and are you unwilling to shift your focus (TUNNEL VISION)?*

Yes
No

10. Are you experiencing periods of minor depression?*

Yes
No

11. Are you experiencing a loss in the ability to plan constructively where attention to details lessen and wishful thinking begins?*

Yes
No

12. Are your plans beginning to fail?*

Yes
No

13. Do you find yourself daydreaming more often and is the “if only” syndrome entering into your daily routine?*

Yes
No

14. Do you feel that nothing can be solved?*

Yes
No

15. Are you vocalizing the immature wish to be happy while feeling that you do not know what happiness is?*

Yes
No

16. Are you experiencing periods of confusion?*

Yes
No

17. Are you behaving irrationally with friends and family?*

Yes
No

18. Are you easily angered?*

Yes
No

19. Do you have irregular eating habits?*

Yes
No

20. Do you feel you have an inability to concentrate feel full of anxiety or have feelings of being trapped?*

Yes
No

21. Has there been a progressive loss of daily structure?*

Yes
No

22. Are you experiencing periods of deep depression?

Yes
No

23. Have you had increasingly irregular attendance at recovery meetings?

Yes
No

24. Have you developed an “I do not care” attitude?

Yes
No

25. Are you openly rejecting help?

Yes
No

26. Are you becoming dissatisfied with life?

Yes
No

27. Do you have feelings of powerlessness and helplessness?

Yes
No

28. Do you spend time wallowing in self pity?

Yes
No

29. Are you having thoughts of social drinking/using?

Yes
No

30. Are you experiencing conscious lying?

Yes
No

31. Do you have a complete loss of self-confidence?

Yes
No

32. Are you harboring unreasonable resentments?

Yes
No

33. Have you discontinued attendance at Recovery Meetings altogether?(“Developed an I do not need them attitude”)

Yes
No

34. Do you feel overwhelming loneliness and frustration and anger and tension?

Yes
No

35. Have you started “controlled” drinking and using?

Yes
No

36. Are you feeling a loss of control?

Yes
No