Addiction: Self Assessment Questionnaire

How often do you use substances or engage in an (addictive) behavior you are assessing?(Required)

Daily	Several times a week	Occasionally	Rarely

Do you experience strong urges or cravings to use substances or engage in this behavior?(Required)

Constantly	Often	Sometimes	Never

Has the amount you use or the frequency of the behavior increased over time?(Required)

Significantly increased	Slightly increased	Stayed the same	Decreased

Has your substance use or behavior negatively impacted your work, school, or home responsibilities?(Required)

Yes, frequently	Yes, but only occasionally	Not sure	No, it has not

Have you lost interest in hobbies or activities you once enjoyed?(Required)

Completely lost interest	Somewhat lost interest	No change in interest	I have more interest now

Has your substance use or behavior caused issues with friends or family members?(Required)

Caused serious issues	Caused some conflict	No issues, but they have expressed concern	No issues at all

Have you tried to cut back or quit but found that you couldn't?(Required)

Multiple failed attempts	A few failed attempts	Never tried to quit	Successfully quit before

Do you find that you need to increase the amount you use or engage in the behavior more frequently to achieve the same effect?(Required)

Yes, regularly	Yes, but only slightly	No noticeable change	I use less for the same effect

When you stop using or engaging in the behavior, do you experience withdrawal symptoms?(Required)

Severe withdrawal symptoms	Mild withdrawal symptoms	Unsure/never stopped	No withdrawal symptoms

Has your substance use or behavior led to financial difficulties?(Required)

Severe financial impact	Some financial strain	Little to no financial impact	No financial impact

Have you engaged in risky behaviors as a result of your use or behavior?(Required)

Frequently take risks	Occasionally take risks	Rarely take risks	Never take risks

Are you concerned about the health consequences of your use or behavior?(Required)

Very concerned	Somewhat concerned	A little concerned	Not concerned

How much of your time is spent obtaining, using, or recovering from the substance or behavior?(Required)

Most of my time	A lot of my time	Some of my time	Very little of my time

Do you find yourself hiding your use or behavior from others, or lying about it?(Required)

Always	Sometimes	Rarely	Never

Have you faced legal problems due to your substance use or behavior?(Required)

Yes, multiple times	Yes, at least once	No, but I've had close calls	No legal problems

Do you prioritize your substance use or behavior over other important life aspects?(Required)

Always prioritize it	Sometimes prioritize it	Rarely prioritize it	Never prioritize it

Do you feel like you cannot stop using or engaging in the behavior even if you wanted to?(Required)

Feel completely unable to stop	Feel somewhat unable to stop	Feel I could stop if necessary	I can stop anytime

Do you use substances or engage in the behavior to improve your mood or alter your state of mind?(Required)

Always	Often	Sometimes	Never

Do you often neglect other sources of pleasure or enjoyment because of your use or behavior?(Required)

Yes, regularly neglect others	Occasionally neglect others	Rarely neglect others	No, I balance well

How does your substance use or behavior affect your self-image?(Required)

Feel bad about myself	Sometimes have negative feelings	It doesn't affect my self-image	Feel good about myself regardless

Your Name or Alias

This is just for reference and not to identify you

Name

This field is for validation purposes and should be left unchanged.

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