This questionnaire consists of twenty-eight questions about experiences that you may have in your daily life. We are interested in how often you have these experiences. It is important that your answers show how often these experiences happen to you when you are not under the influence of alcohol or drugs. For each question, move the slider to show what percentage of the time this happens to you, from 0% (never) to 100% (always).
This form is sent securely and directly to our clinic team, it is not stored anywhere else, and your responses will only be used to support your care.