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My Life Since Treatment/Self Help meetings
1.
What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
2.
What is your gender?
Female
Male
3.
Which race/ethnicity best describes you? (Please choose only one.)
American Indian or Alaskan Native
Asian / Pacific Islander
Black or African American
Hispanic
White / Caucasian
Multiple ethnicity / Other (please specify)
4.
Have You been to treatment for substance issues?
0 times
1-2 times
2 + times
5.
Do you currently attend any type of self help meeting?
Yes infrequently
Yes regularly
No, but I used to
No never
6.
What did you find most helpful about self help meetings?
7.
What did you find least helpful about self help meetings?
8.
If Yes, which kind?
Alcoholics Anonymous
Narcotic Anonymous
Cocaine Anonymous
Different Anonymous
Refuge Recovery
Smart Recovery
Other (please specify)
9.
If you do not attend self help meetings why did you stop?
10.
Do you currently drink alcohol?
Yes, regularly
Yes, occasionally
Rarely
Never
11.
Do you currently smoke marijuana?
Yes, regularly
Yes, occasionally
Rarely
Never
12.
Do you currently smoke cigarettes, or vape?
Yes,regualrly
Yes, occasionally
Rarely
Never
13.
Do you currently take a mood altering prescription?
Yes, regualrly
Yes, occasionally
Rarely
Never
14.
Do you currently take any illegal drugs?
Yes, regularly
Yes, occasionally
Rarely
Never
15.
Who or what is your greatest support for your life changes?
16.
How do you support you life style changes?
17.
Are you in therapy?
Yes, currently
No, but I have been
No, never
18.
Do you meditate?
Yes, regularly
Yes, occasionally
No, but I have in the past
No, never
19.
Do you utilize a prayer life?
Yes
No
20.
Do you exercise?
Yes
No
21.
Please list any method not mentioned that use to enhance your life?
22.
Rate you level of contentment with your life today?
Very content
Somewhat content
Neutral
Somewhat discontent
Very discontent
Contentment level of life
Very content
Somewhat content
Neutral
Somewhat discontent
Very discontent
23.
Do you believe a person can return to controlled use after being identified as addcited?
Yes
No
Sometimes
24.
Could we contact you you for future surveys?
Yes
No
25.
At what email address would you like to be contacted?