Initial assessment: Addiction Questionnaire

This initial assessment consists of seven questions. Please answer them keeping in mind your situation for the past two weeks.

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1. Which addiction do you have?

Alcohol Drugs Nicotine Gambling Internet usage Codependency Sex addiction Other

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2. How long have you had this addiction?

0-1 years 2-3 years 4-10 years Longer than 10 years

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3. Have you had previous therapy or rehabilitation experience for this or other addictions?

Yes No

4. How much does this addiction hamper your daily life at the moment? (scale 1-5)

Not at all A little Somewhat A lot Very much

5. How much does your addiction hamper your work performance at the moment? (scale 1-5)

Not at all A little Somewhat A lot Very much

6. How often do you feel guilt or anxiety because of your addiction?

Never Seldom Sometimes Often Constantly

7. Does your addiction cause problems in your relationships?

Never Seldom Sometimes Often Constantly

All done.

What other addiction do you have?

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What kind of experience?

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