Substance Use Stages of Change Assessment
Please complete this form to help assess your current stage of change regarding substance use. Your responses will remain confidential.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Which substance(s) are you being assessed for? (e.g., alcohol, tobacco, cannabis, prescription drugs, etc.)
*
How often do you use the substance(s) mentioned above?
*
Please Select
Daily
Several times a week
Once a week
A few times a month
Rarely
Not at all in the last month
Please indicate how much you agree with each statement below regarding your substance use.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I do not believe I have a problem with substance use. (Precontemplation)
1
2
3
4
5
I am beginning to think I might need to make changes to my substance use. (Contemplation)
6
7
8
9
10
I am planning to make changes to my substance use soon. (Preparation)
11
12
13
14
15
I have started to make changes to my substance use. (Action)
16
17
18
19
20
I have maintained changes to my substance use for more than 6 months. (Maintenance)
21
22
23
24
25
I have experienced setbacks but am working to get back on track. (Relapse/Recovery)
26
27
28
29
30
Have you previously attempted to change your substance use?
*
Yes
No
How confident are you in your ability to change your substance use if you decided to?
*
Not confident at all
1
2
3
4
5
6
7
8
9
Extremely confident
10
1 is Not confident at all, 10 is Extremely confident
Would you like to receive support or resources to help change your substance use?
Yes
No
Maybe
Please share any additional comments or concerns you may have about your substance use or readiness to change.
Submit Assessment
Should be Empty: