Rehab Matching Survey

Please answer the following questions to help us understand your needs and recommend the best rehab center for you.

1. What is your current age?

2. What is your primary drug of choice? Please select only one. If you use multiple substances, consider this: “If you were stranded on an island for years, and could only use one substance, which one would it be?”

3. Do you ever experience guilt associated with your eating habits? Yes No

4. Are you currently employed? Yes No

5. Do any of your immediate family members or romantic partners use drugs or alcohol excessively? Yes No

6. Have you ever served in the U.S. military? Yes No

Instructions for the Following Sections:

Please answer the following questions about yourself by indicating the extent of your agreement using the provided scale. Be as honest as you can throughout, and try not to let your responses to one question influence your response to other questions. There are no right or wrong answers.

Scale:

0 = Strongly Disagree
1 = Disagree
2 = Neutral
3 = Agree
4 = Strongly Agree

1. In uncertain times, I usually expect the best.

0 1 2 3 4

2. It’s easy for me to relax.

0 1 2 3 4

3. If something can go wrong for me, it will.

0 1 2 3 4

4. I’m always optimistic about my future.

0 1 2 3 4

5. I enjoy my friends a lot.

0 1 2 3 4

6. It’s important for me to keep busy.

0 1 2 3 4

7. I hardly ever expect things to go my way.

0 1 2 3 4

8. I don’t get upset too easily.

0 1 2 3 4

9. I rarely count on good things happening to me.

0 1 2 3 4

10. Overall, I expect more good things to happen to me than bad.

0 1 2 3 4

Now please consider your feelings and thoughts during the last month. In each case, please indicate how often you felt or thought a certain way. Don’t try to count up the number of times you felt a particular way; rather indicate the alternative that seems like a reasonable estimate.

Scale:

0 = Never
1 = Almost Never
2 = Sometimes
3 = Fairly Often
4 = Very Often

1. In the last month, how often have you been upset because of something that happened unexpectedly?

0 1 2 3 4

2. In the last month, how often have you felt that you were unable to control the important things in your life?

0 1 2 3 4

3. In the last month, how often have you felt nervous and stressed?

0 1 2 3 4

4. In the last month, how often have you felt confident about your ability to handle your personal problems?

0 1 2 3 4

5. In the last month, how often have you felt that things were going your way?

0 1 2 3 4

6. In the last month, how often have you found that you could not cope with all the things that you had to do?

0 1 2 3 4

7. In the last month, how often have you been able to control irritations in your life?

0 1 2 3 4

8. In the last month, how often have you felt that you were on top of things?

0 1 2 3 4

9. In the last month, how often have you been angered because of things that happened that were outside of your control?

0 1 2 3 4

10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

0 1 2 3 4

Almost Through!

For this last section, please rate each item below based on how you are feeling at this point in your life. Moving towards the left reflects greater disagreement, while moving to the right reflects greater agreement.

Scale:

1 = Strongly Disagree
3 = Disagree
4 = Agree
6 = Strongly Agree

1. Staying sober is the most important thing in my life.

1 2 3 4 5 6

2. I am totally committed to staying off of alcohol/drugs.

1 2 3 4 5 6

3. I will do whatever it takes to recover from my addiction.

1 2 3 4 5 6

4. I never want to return to alcohol/drug use again.

1 2 3 4 5 6

5. I have had enough alcohol and drugs.

1 2 3 4 5 6

Let’s Get Started

Instructions for the Following Sections:

Almost Through!