Relapse Checklist
Negative Moods
Angry
Guilty
Depressed
Bored
Anxious or Nervous
Tired
Lonely
Hungry
Sexually Frustrated
 
Relapse Thoughts, Feelings, and Attitudes
Urges and cravings Fantasies about controlled use
Impatience Feeling sorry for myself
Overconfidence Feeling hopeless
Expecting too much from others Romanticizing the "good times" on cocaine
Blaming others Feeling good and like celebrating with cocaine
Defiance Feeling hassled and justified in getting high
Argumentativeness Feeling plagued by painful memories
Defensiveness Feeling resentful toward others
Intolerance Having drug dreams
Dissatisfaction Wanting "magical" solutions to problems
Desire to test control Thoughts of dropping out of treatment
Desire to indulge Dwelling on past mistakes
Feeling like giving up Doubting that I'm really an addict
Feeling unable to have fun without drugs Feeling invulnerable to relapse
Feeling elated-that everything is "just fine"    
Relapse Behaviors
"Backdoor setups": being in high-risk situations Failure to take care of physical/medical problems
Impulsive decisions or actions Loss of daily structure
Other addictive/compulsive behaviors Allowing stress and crises to build
Working someone else's recovery program Poor eating habits
Coming later to meetings/sessions Lying
Missing meetings/sessions Rejecting help
Involvement in a new relationship too deeply, too soon Focusing on someone else's problems instead of my own
Failure to exercise Becoming socially isolated, distant, and withdrawn
Failure to plan leisure activities Remaining silent
 
Cocaine Assessment Profile (CAP)
I. Cocaine Use
1.
 How long ago did you first try cocaine?
2.
 How did you use it the first time?
3.
 How long did you use cocaine on an "occasional" basis before your use became regular and intensified?
4.
 Have you ever freebased?
5.
 Have you ever injected cocaine?

6.

 Currently, what is your usual method of use?
7.
 On average, how many grams of cocaine do you use per week? grams
8.
 How much money do you spend on cocaine per week? $
9.
 On average, how many days per week do you use cocaine?
10.
 Do you tend to go on "binges"?
If yes, how long does the binge usually last? days
How many grams do you use during a typical binge? grams

11.

 In what types of situations do you usually use cocaine? (check all that apply)
Alone    At home
With friends At parties
With spouse/mate At work
With other sexual partner       
12.
 During what portion of the day do you usually use cocaine? (check all that apply)
Morning    Afternoon    Evening    Late Night
13.
 Since you first started using cocaine on a regular basis, what is the longest time you've been able to stop completely?
14.
 Check below any physical problems caused by your cocaine use:
Low energy    Hepatitis
Sleep problems Other infections
Hands tremble Heart "flutters"
Runny Nose Nausea
Nasal sores, bleeding    Chills
Sinus congestion Seizures with loss of consciousness
Headaches Excessive weight loss
Cough, sore throat   Other (describe)
Chest congestions  
Black phlegm  
15.
 Check below any negative effects of cocaine on your mood or mental state:
Irritable    Paranoia
Short-tempered Anxiety/nervousness
Depression Panic attacks
Memory problems    Suicidal impulses
Loss of sex drive Violent impulses
 
Other (please describe):
16.
 Check any negative effects of cocaine on you relationships with other people:
Caused arguments with spouse/mate
Spouse/mate has threatened to leave
Caused relationship to break up
Became socially isolated and withdrawn
Harmed sexual relationship
Harmed ability to talk openly and honestly with others
17.
 Check any negative effects of cocaine on your work or studies:
Arrive late to work/school    Spend too much time on breaks
Miss days of work/school Harmed relationship with boss
Reduced productivity at work/school    Got fired from a job
 
Other (please describe):
18.
 Check any negative effects of cocaine use on your financial situation:
Used up all money in bank    Unable to keep up with bills
Gotten in debt No extra money
 
Other (please describe):
19.
 Check any legal consequences of your cocaine use:
Arrested for possession or sale of cocaine
Arrested for other crime(s) related to cocaine sale/use
20.
 Has your cocaine use caused you to:
Have a car accident    Physically hurt someone
Have a physical fight with someone Attempt suicide
Have an unwanted sexual encounter    Deal drugs
    Steal from work, family, or friends
II. Other Drug Use
Marijuana Yes No
Amphetamines Yes No
LSD or other psychedelics Yes No
Valium or other tranquilizers Yes No
Barbiturates Yes No
Quaaludes Yes No
Heroin Yes No
Other opiates Yes No
Alcohol Yes No
 
Relapse Attitude Inventory
1.
 Are you angry that you can't return to "controlled" drug/alcohol use again?
2.
 Are you resisting the idea of not drinking, or smoking marijuana even "occasionally"?
3.
 Are you being superficially compliant with the program and paying "lip service" to the advice you are receiving?
4.
 Are you making promises and commitments about actions you don't follow through on?
5.
 Are you failing to sever ties with drug using friends, lovers, and acquaintances?
6.
 Are you holding onto the phone numbers of your dealers because you think you might possibly want to contact them in the near future?
7.
 Are you holding onto the notion that your dealer is your "friend"?
8.
 Are you serving as a contact, resource, or middleman in drug buys for others?
9.
 Do you allow others to get high in your home?
10.
 Have you failed to discard all drug paraphernalia and drug supplies?
11.
 Are you harboring a secret "stash" in your home, car, safe deposit vault, friend's home, or other secret hiding place?
12.
 If you thoroughly cleaned your home or car, would you "accidentally" come across a drug supply you happened to forget about?
13.
 Do you feel that being in a treatment program means your a loser?
14.
 Do you feel like a helpless victim of your addiction problem?
15.
 Are you immersed in self-pity about your addiction and repeatedly asking yourself "why me"?
16.
 Are you looking to your therapist for "answers" to your addiction problem?
17.
 Are you blindly doing what you are told and nothing more?
18.
 Are you letting others take responsibility for your recovery?
19.
 Are you mechanically following the advice of others so that if it doesn't work out, you can blame your failure on them?
20.
 Are you telling other what they want to hear, attempting to keep them off your back?
21.
 Do you promise yourself and others that you will never get high again?
22.
 Are you hoping that being in treatment will give you the strength to return to controlled drug use again?
23.
 Do you believe you can put yourself in "high risk" situations without being tempted to get high?
24.
 Do you downplay or ignore the risks of being in contact with people, places, and things associated with you prior drug use?
25.
 Do you think that while some addicts may need the "crutch" of AA, CA, or NA, you don't need to rely on others for help?
26.
 Do you believe that a drink or a joint won't impede your recovery in any why?
27.
 Do you consider yourself to be better, smarter, or more "together" than everyone else in your program?
28.
 Do you consider some of the program rules simply not applicable to your particular situation?
29.
 Are you secretly planning to drop out of the program prematurely, hoping to make it on your own thereafter?
30.
 Do you "unavoidably" miss meetings or sessions because of schedule conflicts that could really be removed with a more honest effort on your part?
31.
 Do you consider AA, CA, or NA meetings as undignified, low class, or for losers?
32.
 Do you consider yourself as being intelligent enough to beat the odds and avoid relapse without following advice or making significant lifestyle changes?
33.
 Do you superficially accept the advice of your therapist and peers, but later discount what they say and fail to follow through with their suggestions?
34.
 Are you hoping to find another program or therapist to make recovery easier for you?
35.
 Do you think of your therapist and peers as rigid, narrow-minded, or unable to understand your social needs?
36.
 Are you secretly contemptuous of your therapist or peers?
37.
 Are you being manipulative and deceitful in order to avoid responsibility for your actions or the lack of them?
38.
 Are you determined to have a "perfect" recovery?
39.
 Are you hoping that your determination and willpower to be abstinent will result in a successful recovery?
40.
 Do you set impossible standards and expectations for yourself and others?
41.
 Do you continue to "romanticize" and glorify previous drug experiences?
42.
 Do you argue about insignificant things and insist on being right most of the time?
43.
 Do you tend to magnify difficulties and consider every problem a disaster?
44.
 Do you have trouble admitting faults and weakness?
45.
 Do you tend to blame your problems on others, especially those closest to you?
46.
 Do you attempt to make others feel guilty and defensive when they try to hold you accountable for your behavior?
47.
 Do you believe that recovery is just a matter of staying away from drugs and alcohol?
48.
 Are you focusing on someone else's recovery more than your own?
49.
 Are you generally being negative, blaming, and chronically dissatisfied?
50.
 Are you angry and disappointed because now that you've stopped using drugs, life still isn't going "just fine"?
51.
 Are you angry that the victims of your addiction are not granting you instant trust and forgiveness?
52.
 Are you secretly intending to cut down the frequency of your drug use without stopping it completely?
53.
 Do you believe it impossible to have a satisfying social or sex life without drugs or alcohol?
54.
 Do you feel like your recovery is a lonely endurance test?
55.
 Are you allowing boredom, stress, or other hassles to accumulate so you can justify a return to drugs as inevitable or as a well-deserved "treat" or "relief"?
56.
 Are you engaging in other addictive behaviors (compulsive gambling, eating, sexuality), but not mentioning these problems to your therapist or group?
57.
 Do you remain silent about your problems in-group, rationalizing that the problems of others are more serious or important then yours?
58.
 Are you actively working to build a strong social support network of non-drug friends?
59.
 Are you immersed in guilt about your past behavior and thereby less able to focus on your present behavior in recovery?
60.
 Are you resisting the necessity to change your lifestyle?
61.
 Do you continue to experience frequent drug urges and cravings?
62.
 When you get a craving or urge do you tend to feel that your recovery is failing?
63.
 Do you fantasize about being able to return to using drugs in the future?
64.
 When not at work, do you tend to be idle and alone a lot?
65.
 Do you feel resentful, self-conscious, or self-pitying about not drinking at restaurants, social gatherings, or business meetings?
66.
 Do you have a specific action plan for dealing with cravings and urges?
67.
 Are you reluctant to reach out for help from your group members or others for fear that they will perceive you as imperfect and weak?
68.
 Have you contacted anyone in your group for social reasons or support?
69.
 If you have a relapse, are you likely to leave treatment because of extreme embarrassment and feelings or failure?
70.
 Do you quietly resent being called an addict or alcoholic?
71.
 Do you get urges and cravings as a result of attending group sessions or l2-step meetings?
72.
 Do you blame your drug use on a bad marriage, job stress, financial difficulties, or other major problems in your life?
73.
 Are you afraid to remain abstinent long enough to find out more about yourself and why you use drugs?
74.
 Do you feel that most of your problems would be solved if other people got off-your case and treated you with more understanding?
75.
 Do you find yourself wanting to prove your therapist and peers wrong?
76.
 Do you believe that only someone who is a recovering addict is capable of understanding your problem and helping you with it?
77.
 Are you more focused on differences rather then similarities with other recovering addicts?
78.
 Are you resentful and angry about the investment of money and time you must devote to your recovery?
79.
 Do you tend to think that your treatment program is just a moneymaking scheme and that your therapist doesn't really care what happens to you?
80.
 Do you secretly mistrust your therapist and fell the need to control your treatment plan as much as possible?
81.
 Are you upset and disappointed when the group does not give priority to your issues and problems?
82.
 Do you feel competitive and resentful toward peers who are further along in recover than you are?
83.
 Are you left frustrated and angry when not provided with an immediate, concrete solution to a pressing problem you bring up in a group meeting or therapy session?
84.
 Are you intolerant of recovering peers who fail to agree with you?
85.
 Do you believe that having an addictive disease means that you have no control over whether or not you use drugs again?
86.
 Do you feel doomed to relapse and failure?
87.
 Are you "all talk and no action'' when it comes to making the fundamental lifestyle and attitude changes that are necessary for your recovery?
88.
 Do you spend too much time dwelling on the faults of others?
89.
 Are you too defensive to take an honest personal inventory of your own shortcomings and mistakes?
90.
 Do you have a negative, pessimistic attitude about improving your life?
91.
 Are you resentful that some problems have actually gotten worse since you've stopped using drugs?
92.
 Are you living in a "pink cloud" believing that most problems are behind you?
93.
 Are you angry at others for confronting you about your drug-related behavior?
94.
 Do you fear that your recovery is going to be an intolerable experience?
95.
 Do you have rapid mood swings?
96.
 Do you tend to overreach to stressful situations?
97.
 Are you unproductive and chronically bored or distracted at work?
98.
 Are you chronically irritable, short-tempered, or argumentative?
99.
 If something especially good happened to you, would you be tempted to get high as a way of celebrating?
100.
 Are you alert for early warning signs of relapse and what to do about them in order to avoid returning to drugs?
 
Cocaine Addiction Severity Test (CAST)
1.
 Do you have trouble turning down cocaine when it is offered to you?
2.
 Do you tend to use up whatever supplies of cocaine you have on hand even though you try to save some for another time?
3.
 Have you been trying to stop using cocaine but find that somehow you always go back to it?
4.
 Do you go on cocaine binges for 24 hours or longer?
5.
 Do you need to be high on cocaine in order to have a good time?
6.
 Are you afraid that you will be bored or unhappy without cocaine?
7.
 Are you afraid that you will be less able to function without cocaine?
8.
 Does the sight, thought or mention of cocaine trigger urges and cravings for the drug?
9.
 Are you sometimes preoccupied with thoughts about cocaine?
10.
 Do you sometimes feel an irresistible compulsion to use cocaine?
11.
 Do you feel psychologically addicted to cocaine?
12.
 Do you feel guilty and ashamed of using cocaine and like yourself less for doing it?
13.
 Have you been spending less time with "straight" people since you've been using more cocaine?
14.
 Are you frightened by the strength of your cocaine habit?
15.
 Do you tend to spend time with certain people or go to certain places because you know that cocaine will be available?
16.
 Do you use cocaine at work?
17.
 Do people tell you that your behavior or personality has changed even though they might not know it s doc to drugs?
18.
 Has cocaine led you to abuse alcohol or other drugs?
19.
 Do you ever drive a car while high on cocaine, alcohol, or other drugs?
20.
 Have you ever neglected any significant responsibilities at home or at work due to cocaine use?
21.
 Have your values and priorities been distorted by cocaine use?
22.
 Do you deal cocaine in order to support your use?
23.
 Would you be using even more cocaine if you had more money to spend on it or otherwise had greater access to the drug?
24.
 Do you hide your cocaine use from straight friends or filmily because you afraid of their reactions?
25.
 Have you become less interested in health-promoting activities (e.g. exercise, sports, diet, etc.) due to cocaine use?
26.
 Have you become less involved in your job or career due to cocaine use?
27.
 Do you find yourself lying and making excuses because cocaine use?
28.
 Do you tend to deny and downplay the severity of your cocaine problem?
29.
 Have you been unable to stop using cocaine even though you know that it is having negative effects in your life?
30.
 Has cocaine use jeopardized your job or career?
31.
 Do you worry whether you are capable of living a normal and satisfying life without cocaine?
32.
 Are you having financial problems due to cocaine use?
33.
 Are you having problems with your spouse or mate due to cocaine use?
34.
 Has cocaine use had negative effects on your physical health?
35.
 Is cocaine having a negative effect on your mood or mental state?
36.
 Has your sexual functioning been disrupted by cocaine use?
37.
 Have you become less sociable due to cocaine use?
38.
 Have you missed days of work due to cocaine use?
 
Biopsychosocial Assessment
Date:
Patient Name:
Demographic Data:
Age:       Marital Status:       Race:       Sex:       Children:      
Residence:
Others in residence:
Length in residence:
Education:
Occupation:
Characteristics of Informant:
Chief complaint:
Biopsychosocial Assessment
History of the Present Illness
(age of onset, duration, patterns, and consequences of use, current use, last use, previous treatments, blackouts, and symptoms of abuse or dependence)
Past History
Place of birth:
Date of birth:
Developmental Milestones:
Specific disabilities:
Raised with:
Mother    Brothers
Father Sisters
Birth order:
Significant others:
Ethnic/cultural heritage:
Description of home life:
Grade school:
High school:
Collage:
Military History
Branch:
Highest rank:
Discharge status:
Problems:
Occupational History
Longest job held:
Length of time at current job:
Employment satisfaction:
Work problems:
Financial history:
Current annual income:
Gambling history: Explain:
Sexual History
Sexual orientation:
Physical Abuse:
Sexual Abuse:
Current sexual history:
Relationship history:
Recovery Environment
Family:
Friends:
Spiritual history:
Church:
Denomination:
Attends:
Legal History
Arrests:
Pending litigation
Self-identified strengths:
Self-identified weaknesses:
Leisure activities:
Depression:
Mania:
Anxiety:
Panic attacks
Agoraphobia:
Phobias:
Eating disorder:
Medical History
Illnesses:
Measles
Pneumonia
Mumps
Tonsillitis
Chicken pox
Appendicitis
Whooping cough   
Other:
Hospitalizations:
Tonsillectomy and adenoidectomy    Appendectomy
Chemical dependency    
Allergies:
Environmental allergies:
Medications at present:
Father
Age:
Health:
Description:
Mother
Age:
Health:
Description:
Other relatives with significant psychopathology:
Mental Status Examination
Description:
Age:
Race:
Sex:
Hair:
Eyes:
Distinguishing marks or characteristics:
Appearance:
Dress: "Other" Explain:
Personal hygiene:
Sensorium: "Other" Explain:
Factors affecting sensorium:
Alcohol   
Medications
Drugs
Withdrawal symptoms
Other:
Orientation
Person:
Place:
Time:
Situation:
Attitude toward the examiner:
Motor behavior:
Unusual and inappropriate movements:
Eye contact:
Gait: "Other" Explain:
Primary facial expression during interview: "Other" Explain:
Speech quality:
Speech impairment: "Other" Explain:
Mood: "Other" Explain:
Client report of depression:
Episodes of depression:
Client report of symptoms of depression: "Other" Explain:
Observed signs of anxiety during interview: "Other" Explain:
Client Report of Anxiety:
Episodes of Anxiety:
Client report of symptoms of anxiety: "Other" Explain:
Range of Affect: "Other" Explain:
Thought processes: "Other" Explain:
Thought Content - Preoccupations: "Other" Explain:
Thought Content - Delusions: "Other" Explain:
Description of delusional material:
Quality of delusional Material:
Disorders of perception:
None Tactile hallucinations
Auditory hallucinations Gustatory hallucinations incorporated into delusions
Visual hallucinations Fragmented and not incorporated into delusions
Olfactory hallucinations       
Suicidal Ideation:
Details of current plans:
History of suicidal acts:
Homicidal Ideation:
Details of current plans:
History of violent acts:
Obsessions:
None
Death
Illness
Contamination
Violence   
Doubt
Other 
Compulsions:
None
Checking
Hand washing   
Touching
Counting
 
Other 
Phobias:
None
Insects
Public places
Dogs
Closed spaces   
Social security
Heights
Rodents
Snakes
Travel
Flying    
Other 
Estimated range of intellectual ability:
Abstracting ability:
Disturbances in consciousness:
Concentration:
Memory functions:
Confabulations:
Amnesia:
Impulse control:
Judgment:
Insight: