EVA GREGORY COUNSELING ON LINE - COMPLETE PROBATION CONDITIONS AND SAVE TIME AND MONEY.
EVALUATION PAGE TWO
52. HAVE YOU EVER FELT THE URGE TO TELL SOMEONE OFF?
YES
NO
53. PICK THE NUMBER THAT BEST REPRESENTS YOUR CURRENT LEGAL SITUATION. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST.
54. HAVE THERE BEEN TIMES WHEN YOU FELT LIKE DISOBEYING PEOPLE IN POWER EVEN THOUGH YOU KNEW THEY WERE RIGHT?
YES
NO
55. HAS YOUR DRINKING EVER CAUSED PROBLEMS WITH YOUR FAMILY AND/OR FRIENDS?
YES
NO
56. DO YOU FIND IT DIFFICULT TO GET ALONG WITH LOUD-MOUTHED, "BOSSY", OR OBNOXIOUS PEOPLE?
YES
NO
57. DO YOU TRY SOME TYPE OF SOCIAL/STREET DRUG AT LEAST FOUR TIMES A MONTH? DO NOT INCLUDE ALCOHOL.
YES
NO
58. HAS YOUR WIFE/HUSBAND OR CHILDREN EVER BEEN IN COUNSELING REGARDING EMOTIONAL OR BEHAVIORAL PROBLEMS? IF YOU HAVE NEVER BEEN MARRIED, ANSWER "NO".
YES
NO
59. HAS YOUR WIFE/HUSBAND ATTENDED AN ALANON MEETING BECAUSE OF YOUR DRINKING? IF YOU HAVE NEVER BEEN MARRIED OR IF YOU DO NOT KNOW WHAT ALANON IS, ANSWER "NO".
YES
NO
60. HAVE YOU ATTENDED, OR THOUGHT ABOUT ATTENDING, AN A.A. MEETING BECAUSE OF YOUR DRINKING?
YES
NO
61. DO YOU LIKE TO GOSSIP AT TIMES?
YES
NO
62. HAVE YOU EVER FELT THAT YOU WERE PUNISHED WITHOUT CAUSE?
YES
NO
63. PICK THE NUMBER THAT BEST REPRESENTS YOUR FINANCIAL SITUATION AT THIS TIME. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST.
64. DO YOU FEEL GUILTY ABOUT YOUR USE OF DRUGS OR MEDICATION? DO NOT INCLUDE ALCOHOL.
YES
NO
65. HAVE YOUR FAMILY AND/OR FRIENDS EVER COMPLAINED ABOUT YOUR USE OF DRUGS OR MEDICATION? DO NO INCLUDE ALCOHOL.
YES
NO
66. BEFORE VOTING, DO YOU VERY CAREFULLY INVESTIGATE THE BACKGROUND AND RECORD OF EACH PERSON RUNNING FOR OFFICE?
YES
NO
67. HAVE YOU EVER INTENSELY DISLIKED ANYONE?
YES
NO
68. HAS YOUR WIFE/HUSBAND/FRIEND EVER THREATENED TO LEAVE BECAUSE OF YOUR DRINKING?
YES
NO
69. MORE THAN ONCE, HAVE YOU GOTTEN VIOLENTLY ANGRY WHILE DRINKING?
YES
NO
70. HAVE THERE BEEN TIMES WHEN YOU TOOK ADVANTAGE OF SOMEONE?
YES
NO
71. ON OCCASION, HAVE YOU HAD DOUBTS ABOUT YOUR ABILITY TO SUCCEED IN LIFE?
YES
NO
72. HAVE YOU TRIED SEVERAL TIMES TO STOP DRINKING, BUT ENDED UP DRINKING AGAIN?
YES
NO
73. HAVE THERE BEEN SOME OCCASIONS WHEN YOU FELT LIKE SMASHING THINGS?
YES
NO
74. PICK THE NUMBER THAT BEST REPRESENTS YOUR CURRENT FAMILY LIFE. ENTER 0 IF THIS DOES NOT APPLY TO YOU. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST.
75. DO YOU SOMETIMES FEEL ANGRY WHEN YOU DON'T GET YOUR OWN WAY?
YES
NO
76. HAVE YOU EVER FOGOTTEN OR OVERLOOKED YOUR DUTIES, YOUR FAMILY, OR YOUR WORK FOR TWO OR MORE DAYS IN A ROW BECAUSE OF YOUR DRINKING?
YES
NO
77. ARE YOU ALWAYS COURTEOUS, EVEN TO PEOPLE WHO ARE DISAGREEABLE?
YES
NO
78. HAVE YOU EXPERIENCED PHYSICAL AND EMOTIONAL AFTER EFFECTS RESULTING FROM HEAVY DRUG USE?
YES
NO
79. DO YOU SOMETIMES TRY TO GET EVEN RATHER THAN FORGIVE AND FORGET?
YES
NO
80. AT LEAST ONCE WHILE DRINKING, HAVE YOU THOUGHT ABOUT KILLING YOURSELF?
YES
NO
81. SOMETIMES DO YOU HAVE TO HIDE THE FACT THAT YOU HAD BEEN DRINKING?
YES
NO
82. DO YOU USUALLY TAKE MEDICATION TO HELP YOURSELF SLEEP AT NIGHT?
YES
NO
83. IF YOU COULD GET INTO A MOVIE WITHOUT PAYING AND BE SURE YOU WERE NOT SEEN, WOULD YOU PROBABLY DO IT?
YES
NO
84. PICK THE NUMBER THAT BEST REPRESENTS YOUR FEELINGS ABOUT YOURSELF IN THE PAST YEAR. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST.
85. AFTER A NIGHT OF HEAVY DRINKING, DOES A DRINK THE NEXT MORNING USUALLY HELP GET YOU GOING?
YES
NO
86. AFTER A NIGHT OF HEAVY DRINKING, THE NEXT MORNING DO YOUR HANDS NOTICEABLY SHAKE?
YES
NO
87. DO YOU ALWAYS ADMIT IT WHEN YOU MAKE A MISTAKE?
YES
NO
88. DO YOU ALWAYS PRACTICE WHAT YOU PREACH?
YES
NO
89. HAVE YOU TRIED SEVERAL TIMES TO STOP USING DRUGS, BUT ENDED UP USING AGAIN?
YES
NO
90. TO AVOID EYE STRAIN DURING A LONG TRIP, SHOULD YOU MOVE YOUR EYES ACROSS THE ROAD FREQUENTLY RATHER THAN JUST STARE AT THE ROAD AHEAD OF YOU?
YES
NO
91. HAVE YOU EVER LOST A JOB BECAUSE OF DRINKING?
YES
NO
92. HAS A DOCTOR OR HEALTH PROFESSIONAL EVER TOLD YOU TO STOP DRINKING?
YES
NO
93. WHEN DRIVING NEAR HOMES, SHOULD YOU WATCH OUT FOR CHILDREN DARTING INTO THE STREETS?
YES
NO
94. IS IT SOMETIMES HARD FOR YOU TO GO ON WITH YOUR WORK IF YOU ARE NOT ENCOURAGED?
YES
NO
95. FROM THE LIST BELOW, ENTER THE NUMBER OF THE ITEM THAT YOU USED OR TRIED MOST OFTEN DURING THE PAST THREE YEARS.
0 NONE
1 ALCOHOL
2. SEDATIVES & HYPNOTICS
3. BARBITURATES
4. TRANQUILIZERS
5. HEROIN
6. OTHER NARCOTICS
7. COCAINE
8. CRACK
9. AMPHETAMINES
10. HALLUCINOGENS
11. INHALANTS
12. MARIJUANA
13. OTHER DRUGS (STEROIDS, ETC.)
96. WHEN WAS THE LAST TIME THAT YOU USED THIS DRUG (THE ITEM SELECTED IN QUESTION 95)? ENTER 0 IF YOU ENTERED 0 FOR QUESTION 95.
0 NEVER USED
1. TODAY
2. YESTERDAY
3. WITHIN THE PAST WEEK
4. TWO TO FOUR WEEKS AGO
5. ONE TO TWO MONTHS AGO
6. THREE TO SIX MONTHS AGO
7. MORE THAN SIX MONTHS AGO
8. MORE THAN A YEAR AGO
97. FROM THE LIST SHOWN AT QUESTION 95, ENTER THE NUMBER OF THE ITEM THAT YOU USED SECOND MOST OFTEN DURING THE PAST THREE YEARS.
98. WHEN WAS THE LAST TIME THAT YOU USED THIS DRUG (THE ITEM YOU SELECTED IN QUESTION 97)? ENTER 0 IF YOU ENTERED 0 FOR QUESTION 97).
0 NEVER USED
1. TODAY
2. YESTERDAY
3. WITHIN THE PAST WEEK
4. TWO TO FOUR WEEKS AGO
5. ONE TO TWO MONTHS AGO
6. THREE TO SIX MONTHS AGO
7. MORE THAN SIX MONTHS AGO
8. MORE THAN A YEAR AGO
INDICATE THE NUMBER OF TIMES YOU HAVE BEEN ARRESTED FOR AN ALCOHOL/DRUG RELATED OFFENSE.
HOW MANY TIMES HAVE YOU BEEN IN AN IN-PATIENT (HOSPITAL, ETC.) TREATMENT PROGRAM FOR ALCOHOL AND/OR DRUGS?
HOW MANY TIMES HAVE YOU BEEN IN AN INTENSIVE OUTPATIENT (IOP) PROGRAM?
HOW MANY TIMES HAVE YOU BEEN IN SUPPORTIVE OUTPATIENT (SOP) TREATMENT PROGRAM?
YOUR FULL NAME
YOUR MAILING ADRESS INCLUDING THE ZIP CODE
SPN#
YOUR CAUSE NUMBER
YOUR DATE OF BIRTH
CELL PHONE NUMBER
PROBATION OFFICER'S NAME AND FAX NUMBER
THE DATE YOU COMPLETED THE EVALUATION
PLEASE STATE THE CURRENT E-MAIL THAT YOU WANT THE SUMMARY LETTER OF YOUR ALCOHOL AND DRUG EVALUATION SENT TO:
THE TIME YOU COMPLETED THE EVALUATION.
Hours
 
 : 
Minutes
 
THANK YOU FOR USING THE ONLINE EVALUATION. WITHIN 24 HOURS, MRS. GREGORY WILL SUBMIT YOUR ANSWERS TO ADE, INC. AND GET THE REPORT. IF YOU HAVE NOT HEARD FROM MRS. GREGORY IN 24 HOURS, PLEASE CALL 832-257-4550 OR 832-257-5996.
 
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