Psychological test batteries

Republic of the PhilippinesCity of Iligan

OFFICE OF THE CITY MAYORIligan City Drug Treatment and Rehabilitation Center

Sitio Fatima, Brgy. Abuno Iligan City

PERSONAL DRUG USE QUESTIONNAIRE(SOCRATES 8D)

Please read the following statements carefully. Each one describes a way that you might (or might not) feel about your drug use. For each statement, circle one and only one number for every statement

Checklist of QuestionnairesNo

Strongly Disagre

e

No Disagre

e

?Undecid

ed/Unsure

YesAgree

YesStrongly

Agree

Q1 I really want to make changes in my use of drug. 1 2 3 4 5

Q2 Sometimes I wonder if I am an addict. 1 2 3 4 5

Q3 If I don’t change my drug use soon, my problems are going to get worse.

1 2 3 4 5

Q4 I have already started making some changes in my use of drugs.

1 2 3 4 5

Q5 I was using drugs too much at one time, but I’ve managed to change that.

1 2 3 4 5

Q6 Sometimes I wonder if my drug use is hurting other people

1 2 3 4 5

Q7 I have drug problem 1 2 3 4 5

Q8 I’m not just thinking about changing my drug use; I’m already doing something about it.

1 2 3 4 5

Q9 I have already changed my drug use, and I am looking for ways to keep from slipping back to my old pattern.

1 2 3 4 5

Q10 I have serious problems with drugs. 1 2 3 4 5

Q11 Sometimes I wonder if I am in control of my drug use. 1 2 3 4 5

Q12 My drug use is causing a lot of harm. 1 2 3 4 5

Q13 I actively do things now to cut down or stop my use of drugs.

1 2 3 4 5

Q14 I want help to keep from going back to the drug problems that I had before

1 2 3 4 5

Q15 I know I have a drug problem. 1 2 3 4 5

Q16 There are time when I wonder if I use drug too much 1 2 3 4 5

Q17 I am a drug addict. 1 2 3 4 5

Q18 I am working hard to change my drug use 1 2 3 4 5

Q19 I have made some changes in my drug use; I want some help to keep from going back to the way I used before.

1 2 3 4 5

Source: Miller, W. R., & Tonigan, J. S. (1996). Assessing drinkers' motivation for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors 10, 81-89.




DRUG SCREEN INVENTORY

Kining sumusunod na mga pangutana mahintungod kini sa imong paggamit ug droga sulod sa miaging tuig. Pag-circle kung “OO” o”DILI” kada pangutana base kini sa imong kaugalingong “experience” o “kaagi” sa imaging Dose (12) ka bulan.

Sa imaging Dose (12) ka bulan…

1. Has your drug use affected your ability to take care of your Responsibility? Ang imong paggamit sa droga nakaapekto bas a imong abilidad o kakayahan sa pag dumala sa

imong responsibilidad? OO DILI

2. Have you used drugs in situations where you could have been physically hurt? Ninggamit ba ikaw ug droga sa mga sitwasyon kung asa ikaw napasakitan ang imong kaugalingon? OO DILI

3. Has your drug use resulted in problems with the law? Ang imong paggamit bas a droga maoy us aka hinungdan nga problema sa balaod? OO DILI

4. Have you kept using drugs even though it caused problems with family, friends or other people? Nagapabilin ka ba sa paggamit sa droga maski mao kini ang usa ka hinungdan sa problema diha sa

pamilya,mga amigo o sa uban tao?OO DILI

5. Have you had to use larger amounts of a drug to get the same effect before? Ningamit ka ba ug mas dakong kantidad sa droga aron makakuha ug parehong epekto sama sa

kaniadto?OO DILI

6. Have you experience withdrawal symptoms or used drugs to make withdrawal symptoms go away Nakasinato kaba ug pagkurog-kurog, pagsuka-suka ogitawag nga withdrawal symptoms o magamit

na lang sa droga aron dili ikaw masulay sa maong mga sintomas?OO DILI

7. Have you used larger amounts of drugs or for a longer time than you meant for? Migamit ba ikaw ug mas dakong kantidad sa droga o para sa mas taas nga panahon kaysa

naandan?OO DILI

8. Have you often wanted to cut down on your drug use, or tried to cut down and couldn’t? Gipanapaningkamotan ba nimong maundangan ang imong paggamit sa droga, o misulay sa pag-

undang apan dili nimo mabuhat?OO DILI

9. Have you spent a great deal of time getting ,using or getting over the effects of the drugs? Mihatag ba ikaw ug dakong panahon, paggamit o nagpabilin dinha sa epekto sa droga? OO DILI

10. Have you given up important activities because of drug use? Imo bang gi-undang o gi-surrender ang mga importanteng aktibidades o buluhaton tungod sa

imong paggamit sa droga?OO DILI

11. Have you kept using drugs even though you knew it could make you more physically sick or imotionally upset than usual?

Nipabilin ka ba ug paggamit sa droga bisan kabalo ka nga mao kini ang kinungdan sa mas grabeng mga sakit sa panglawas o dali lang masuko kesa kaniadto?

OO DILI

NAME: _____________________________________ DATE: __________________




THE MICHIGAN ALCOHOLISM SCREEN TEST (MAST)

Please circle either YES or NO for each items that applies to you.

1. Do you feel you are a normal drinker? (By normal we mean you drink less than or as much as most other people.)

YES NO

2. Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening?

YES NO

3. Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking?

YES NO

4. Can you stop drinking without a struggle after one or two drinks? YES NO5. Do you ever feel guilty about your drinking? YES NO6. Do friends or relatives think you are a normal drinker? YES NO7. Are you able to stop drinking when you want to? YES NO8. Have you ever attended a meeting of Alcoholics Anonymous (AA)? YES NO9. Have you gotten into physical fights when drinking? YES NO10. Has your drinking ever created problems between you and your wife, husband, a parent, or other relative?

YES NO

11. Has your wife, husband (or other family members) ever gone to anyone for help about your drinking?

YES NO

12. Have you ever lost friends because of drinking? YES NO13. Have you ever gotten into trouble at work or school because of drinking? YES NO14. Have you ever lost a job because of drinking? YES NO15. Have you ever neglected your obligations, your family or your work for two or more days in a row because you were drinking?

YES NO

16. Do you drink before noon fairly often? YES NO17. Have you ever been told you have liver trouble? Cirrhosis? YES NO18. After heavy drinking have you ever had Delirium Tremens (D.T.s) or severe shaking, or heard voices or seen things that really were not there?

YES NO

19. Have you ever gone to anyone for help about your drinking? YES NO20. Have you ever been in a hospital because of drinking? YES NO21. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital where drinking was part of the problem that resulted in hospitalization?

YES NO

22. Have you ever been seen at a psychiatric or mental health clinic, or gone to any doctor, social worker, or clergyman for help with an emotional problem, where drinking was part of the problem?

YES NO

23. Have you ever been arrested for drunk driving, driving while intoxicated, or driving under the influence of alcoholic beverages?

YES NO

24. Have you ever been arrested, or taken into custody even for a few hours, because of other drunk behavior?

YES NO

Source: Selzer ML: The Michigan Alcoholism Screening test (MAST): The Quest for a New Diagnostic Instrument. American Journal of Psychiatry 3:176-181, 1975




NAME: ______________________________ DATE:_____________

ALCOHOL AND DRUG ADDICTION TESTTo be addicted means that you cannot stop using alcohol or drugs without help. This was adopted from the Jellinek chart for Addiction.

Instructions: Read each question and think back over your life, If this has ever happened to you make a check mark in the left column (yes). If this has never happened to you, make a check mark in the right column (No).

(Basaha ang matag-usa ka pangutana ug lantawa ang imong kinabuhi. Kung nahitabo na kini kanimo, butang ug tsek ang wala nga column (yes). Kung wala pa kini mahitabo kanimo, butangi ug tsek ang tuo nga column (No).

Yes No ___ ___ 1. Use to feel better: I use alcohol or drugs to get away from things that bother me or hard to face

Mugamit para maging o.k. ang bation: Nagagamit ko ug alcohol o droga para makalingkawas sa mga butang na naga-samok samok sa ako o kanang mga sitwasyon na

lisod atubangon.____ ______2. Use to solve most problems: I use alcohol or drugs to try to solve most of my problems and things that bother me.

Mugamit pa ra ma sulbad ang kadaghanan sa mga problema: Nagagamit ako ug alcohol o droga para paningkamutna na masulbad ang kadagahanan sa akong mga problema o mga butang na naga-samok kanako.

_____ _____3. It takes more: It takes more or stronger kind of alcohol or drugs to get the same feelings that it used to.

Kinahanglan na daghan: Mas daghan o mas isog pa nga mga kalse na alcohol o droga ang akong ginagamit para akong bati-on ang pareho sakong gaibati katong niagi nakong paggamit.

____ _____ 4. Memory Loss: Sometimes after I have been using, I do not remember what happened.Pagkawala sa memorya: Usahay, paghuman nako ug gamit, dili nako makahinomdom kung unsa ang nahitabo.

____ _____ 5. Sneaking: Sometimes I hide from other people how much I’m using or drinking. This might be because I do not want people to know or because I do not want to share.

Pagtago-tago: Usahay, itago naku sa uban tao kung unsa kadaghan akong ginagamit o gina-inom kay dili ko gusto makabalo ang mga tao o mahitungod kini kay dili ko gusto mag-share.

_____ ______6. Dependence: I rarely do anything for fun unless I use alcohol or drugs.Dili kayo ko malingaw kung dili ko mogamit ug alcohol o droga.

_____ ______7. Fast start: I use stronger alchohol or drugs or use a lot quickly at first to get a “good start.”

Nagagamit ako ug mas isog na ilimnon o droga o paspas kayo ko mogamit ug daghan nga droga/ilimnon para makuha ang “good start”.

____ ______8. Feel guilty: I feel guilty about using alcohol or drugs or about the thing that I do when I use.




Gibati ug ka-konsiensya: Gibati ko ug ka-konsiyensya batok sa paggamit ug alcohol/droga o batok sa mga butang na akong ginabuhat kapag nagagamit ko.

____ ______9. Do not listen: Other people complain or try to talk to me about my using but I do not listen.

Dili maminaw: Naga-reklamo ang uban tao o ginastoryahan ko sa uban tao batok sa akong paggamit, apan, dili ko maminaw.

____ ______10. Regular blackout: I do not remember what happened and I get into trouble when I use alcohol or drugs.Dili ko mahinomdom kung unsa ang nahitabo ug mapa-trouble ko kada-gamit nako ug alcohol or drugs.

____ ______11. Excuses: I use problems in my life as an excuse for using alcohol or drugs. I feel that I have to use to deal with these problems.Ginahimo nakong “alibi” ang mga problema sakong kinabuhi para lang makagamit ug

droga or alcohol. Akong gibati na kelangan ko mogamit para atubangon kining akong mga problema.

____ ______12. Using more than others: I use more than most people, so I hang around people who as

much or more so that I feel that I fit in. Mugamit ug mas daghan pa kesa sa uban. Mas daghan akong ginagamit kesa sa uban tao, mao nang muuban ko sa mga taong pareho nako o mas grabe pa sa ako mugamit para lang akong bati-on o.k. ko.

____ ______13. Feel bad: I feel bad about how my using hurts other people, but I don’t know what to do about it. Lain ang bati-on: Lain akong gibati batok sa kahiubos na ginabatti sa uban tao tungod sa akong paggamit, pero wala ko kabalo kung unsa ang akong buhahton.

____ ______14. Show off: I show off or get pushy with other people to ffel bettet and prove that I am okay. Pakitang tao/Pagpanghambog: Nagapang-hambog ko sa uban tao para maayo ang akong bati-on ug para ma-prove na o.k. ko.

____ ______15. Promises: I show off or get pushy with other people to feel better and prove that I am okay. Promise to get my life in order and do better. I mean it, but it doesn’t work out

that way.Pakitang tao/Pagpanghambog: Nagapang-hambog ko sa uban tao para maayo ang

akong bati-on ug para ma-prove na o.k. ko.____ ______16. Control: I try to control my use, but it doesn’t work.

Kontrol: Akong ginapaningkamutan na i-kontrol akong paggamit, pero dili kini magsilbi.

____ ______17. Give up other things: I’ve stopped doing things that I used to do that didn’t involve using alcohol or drugs. I give-up ang uban butang: Akong gi-undangan ug buhat ang mga butang ug mga aktibidades na akong ginabuhat tong una.

____ _____ 18. Make changes: I can change jobs, move or leave a relationship to try to make my life better, but it doesn’t make any difference.Pagbuhat ug kabag-ohan: Nagkambyo ko ug trabaho, ug mibiya sa akong karelasyon para lang ayoson ang akong kinabuhi pero wala lang gihapoy nahitabonga kabag-ohan.

____ _____19. Work and money troubles: I have problems on the job, owe money or can’t work at all because of my using.




Problema sa trabaho ug kwarta: Nagkaproblema ko sa trabaho, naka-utang ug kwarta o dili makatrabaho tungod sa akong paggamit.

____ _____20. Avoid friends and family: I avoid old friends and family that do not use-unless I need something from them.

Gina-iwassan ang mga amigo ug pamilya: akong gaina-iwasan akong mga higala ug kapamilya nga wala nagagamit puwera lang kung naa ko’y kinahanglan.

____ _____21. Neglect food: I do not eat healthy foods or eat at regular times, especially when I am using.

Pasagdahan ang pagkaon: Wala ko naaga-kaon ug “healthy” nga pagkaon o mukaon sa saktong oras labaw na kung magagamit ko.

____ ____22.Resentment: I feel like other people are out to get me, and I feel angry a lot. Pagdumot: Akong gibati na ang uban tao nagabantay sa ako. GIbati ko ug kasuko.

____ ____23. Withdrawal: I need a drink or a drug in the morning or else I get the shakes or sweats because I feel terrible.

Kailangan naku mu-inom o mag droga sa buntag. Kung dili ko ni buhaton, magkorog ko ug panington kay terrible akong gibuhat.

____ ____24. Can’t make decisions: I can’t make decisions about even small things. I just wait until things

happen.Dili maka-desisyon: Dili ko maka-desisyon maski sa mga gagmay nga butang. Maghulat lang ko kung nay mahitabo.

____ ______25.Health Problems: I am sick, have lost a lot of weight, or feel physically bad most of the time.Problema sa kalusugan. Nakasakit ako, namayat ug taman o nagbaba ang timbang o kanunay lain ang gibati sa akong kalawasan.

____ ______26. Decrease in amount to get high : It takes less for me to get high or doesn’t matter how much I use because I can’t get the effect I want. Nagkagamay na maount sa droga para ma-high: Ma “high” nako maski gamay lang akong gamiton o usahay, dili na mu-ipekto maski unsa kadaghan ako gamiton kay tungod dili na nako makuha ang epekto sa droga na akong gusto.

____ ______27. Over the line: I do things I said I would never do or things that do not reflect the way I was raised. Pagkalihis: Ginabuhat naku ang mga butang na ingon ko tong una dili nako buhaton, o ginabuhat nako ang mga butang na kabaliktaran kung gi-unsa ko pagpadako sa akong ginikanan/kapamilya.

____ ______28. Use all the time: I use whenever I can, and don’t try to have a normal life.Mugamit sa tanang oras: Mugamit ko kung kanus-a nako gusto mugamit. Wala ko maningkamot nga mabuhi sa normal nga kinabuhi.

____ ______ 29. Find someone worse: I try to use with people who are worse off than I am so that I feel

better. Mangita ug kauban na mas grabe: Mugamit ko ug droga/alcohol na kauban ang mga taong mas grabe pa sa ako para bati-on ug mas o.k.

____ ______30. Major damage: Even when I’m nor using, I have hard time thinking, remembering and doing things that used to be easy. Dakong kadaotan: Maski wala ko magamit, maglisod ako na maka-hunahuna, makahinumdom ug buhaton ang mga butang na akong ginabuhat tong una.

____ ______31. Afraid: I feel like something terrible might happen to me, people are out to get me, and I have to be on guard at all times.




Mahadlokon: Akong gibati na nay terrible na puwedeng mahitabo sa ako, ginabantayan ko sa mga tao ug mas dapat mani-id ko sa tanang panahon.

____ ______32. Give-up: I don’t try to change anything, I just want to see what happens. Give-up: wala ko nagapaningkamot na mabag-o o bag-ohon ang maski unsa. Nagahulat lang ko kung unsa ang mahitabo.

____ _____ 33. Using is everything: Getting something to use, using and getting over using are my whole life.Ang paggamit ang kinabuhi: Pagkuha, paggamit ug paglimot sa paggamit ang akong kinabuhi.

____ _____34. Turn to God: I want God or religion to save me from my life.Pagdangop sa Ginoo: Gusto nako ang Gino-o o relihiyon na mu-salbar sa akong

kinabuhi. ____ _____35. I’m lost: I don’t try to pretend my life is normal. I know I am an addict or an alcoholic. I

believe that things will never change.Nawala ko: Wala nako ginapaningkamutan na magpaka-aron ingnon na normal ang akong kinabuhi. Kabalo ko na ako usa ka adik/alkoholik. Nagtuo akp na dili na magbag-o pa ang mga butang.

____ _____36. Desperation: I am willing to do anything to get better Pagka-desperado: Buhaton nako ang tanan para lang maayo.

____ _____37.Confinement: I have been in jails and mental wards because of my using. Pagka-priso/pagka-kulong: Napriso ko ug nasulod sa mga mental wards tungod sa akong paggamit.




Complete the following sentences.(Kumpletuha ang mga pahayag.)

o If I do not stop using, I will probably …. (Kung dili ko muundang ug gamit, mamahimo akong ……..) _____________________________________________________________________________________________________________________________________________________________________________________________________________

o If I do not stop using, I might be able to …. (Kung dili ko muundang ug gamit, basin makabuhat ko ug …..) ______________________________________________________________________________________________________________________________________________________________________________________________________

REACTIONS: Complete the sentences below and think about what they mean for your recovery. (Kumpletuha ang mga pahayag ug huna-hunnaa kung unsa nag buot-pasabot ani sa

imong pagka-ayo.)

1. How do you feel about the results of the test you just took?(Unsa ang imong gibati sa mga resulta sa “test” na imong gikuha?)____________________________________________________________________________________________________________________________________________________________________________________________________________

2. What do you think about the results of the test you just took?(Unsa ang imong gihuna-huna sa mga resulta sa “test” na imong gikuha?)____________________________________________________________________________________________________________________________________________________________________________________________________________

3. How do you want to do about the results of the test you just took?(Unsa ang imong gusto buhaton, karon, na nakabalo naka sa mga resulta sa “test” na imong gikuha?)____________________________________________________________________________________________________________________________________________________________________________________________________________




SELF REPORTING QUESTIONNAIRE (SRQ)

1. Do you often have headaches?(Madalas bang sumakit ang iyong ulo?)

2. Is your appetite poor?(Wala ka bang gana sa iyong pagkain?

3. Do you sleep badly?(Hindi ka ba nakakatulog ng maigi?)

4. Are you easily frightened?(Ikaw ba’y medaling matakot?)

5. Do you feel nervous, tense or worried?)(Ikaw ba’y ninenerbyos, nag-aalala at nababalisa?)

6. Do your hands shake?(Nanginginig ba ang iyong mga kamay?)

7. Is your digestion poor?(Ang panunaw mo ba sa pagkain ay hindi maayos?

8. Do you have trouble thinking clearly?(Ikaw ba’y nahihirapang mag-isip ng maayos?)

9. Do you feel unhappy?(Ikaw ba’y hindi maligaya?

10.Do you cry more than usual?(Ikaw ba’y umiiyak ng mas madalas kaysa pangkaraniwan?)

11.Do you find it difficult to enjoy your daily activities?(Nahihirapan ka bang gumawa ng desisyon?)




12.Do you find it difficult to make a decision?(Nahihirapan ka bang gumawa ng desisyon?)

13.Is your daily work suffering?(Ang iyong pang- araw-araw na Gawain ba ay naabala?)

14.Are you unable to play a useful part in life?(Ikaw ba ay hindi makaganap ng makabuluhang papel sa buhay?)

15.Have you lost interest in things?(Nawalan ka ba ng interes sa mga bagay-bagay?)

16.Do you feel that you are a worthless person?(Sa pakiramdam mo ba ikaw ay walang halaga?)

17.Has the thought of ending your life been in your mind?(Ang pagkitil sa iyong buhay ay pumasok na ba sa iyong kaisipan?)

18.Do you feel tired all the time?(Nakaramdam ka ba ng di-kaginhawahan sa sikmura?)

19.Do you have uncomfortable feelings in your stomach?(Nakaramdam ka na ba ng di-kaginhawahan sa sikmura?)

20.Do you drink alcohol more than usual?(Madalas ka bang uminom ng alak/tuba kaysa dati?)

21.Do you feel that somebody has been trying to harm you in some way?(Sa pakiramdam mo ba ay may nagtangkang manakit sa iyo?)

22.Have you noticed any interference or anything unusual with your thinking?(Ikaw ba ay nakakapuna ng sagabal o anumang di-pangkaraniwan sa iyong pag-iisip?)

23.Do you ever hear voices without knowing where they come from or which other people cannot hear?(Ikaw ba’y nakakarinig ng mga tinig na hindi moa lam kung saan nagmula o kaya’y hindi naririnig ng ibang tao?)




24.Have you ever had any fits, convulsions or fall to the ground, with movements of the arms and legs, biting of tongue or loss of consciousness? (Nagkaroon ka na ba ng sumpong, kombulsiyon o pagkahulog sa lupa na may kasamang panginginig ng mga ka may at paa, pagkagat ng dila o pagkawala ng malay?)

25.Have you been living recurrent dreams or nightmares about the disaster that had happened?(Nakakaranas ka ba ng paulit-ulit na panaginip tungkol sa kalamidad/sakuna/krisis/aksidente na nangyari?)

26.Have you been having flash backs of what had happened during the disaster at times when you did not want to think of it or even during times when there was nothing to remind you of it?(Nakakaranas ka ba ng madalas na pagbabalik gunita ng mga nangyayaring sakuna noong may kalamidad?)

27.Do you feel bad(e.g. break inn sweat, heart pounding, difficulty of breathing) when you are in a situation that reminds you of the disaster?(Sumasama ba ang pakiramdam mo kagaya ng pinagpapawisan ng malagkit, kumakabang dibdib, nahihirapang huminga kung ikaw ay nasa sitwasyong nakakapag-paalala sa iyo ng sakuna/aksidente/trahedya?)

28.Do you make it a point to stay away from places that reminds you of the disaster?(Sinisiguro mo ba na gumawa ng paraan na lumayo sa mga lugar na nakapagpapaalala sa iyo ng sakuna/aksidente/trahedya?

29.Do you experience the feeling of numbness or having no feeling at all?(Nakaramdam ka na ba ng pamamanhid o parang wala kang nararamdaman?)

Summary:

Positive SRQ if there are > 5 Yes Answers for Questions 1 to 20




Positive SRQ if there are > 1 Yes Answers for Question 21 to 24Positive SRQ if there are > 1 Yes Answers for Question 25 to 29




PSYCHOLOGICAL REPORT

1- Identifying Data

Name: _____________________________ Date of Admission: _______________Age/Sex: ___________________________ Date of Interview: ________________Home Address: ______________________ Date of Admission: _______________Date of Birth: _______________________ _______ VoluntaryCivil Status: _________________________ _______ Court CaseEducational Attainment: _______________Religion: ____________________________Occupation: _________________________

II- Reason for Referral

A psychological assessment as a part of a comprehensive case study, meant to provide the basis for psychosocial therapy or therapeutic intervention and proper case management.

III- Assessment Procedure Date Administered

Michigan Alcoholism Screening Test (MAST) ________________Readiness for Treatment (RFT) ________________Alcohol and Drug Addition Test (ADAT) ________________Drug Screen Inventory (DSI) ________________Level of Smoking (LS) ________________Hostility Test (HT) ________________Raven’s Progressive Matrices (RPM) ________________Bender Gestalt Visual Motor Test (BG VMT) ________________Draw a Person Test (DAP) ________________House Tree Person Test (HTP) ________________IQ and Personality Test (PT) ________________Sentence Completion Test (SACHS) ________________Hand Test (HT) ________________

IV- Substance Used/History

Type of Substance Age of First Use Why Began Frequency Age/Date last Use




Substance Dependence

Tolerance:

_______ Increased amounts of the substance to achieve the intoxication or desired effect.

_______ Continued use of the same amount of the substance.

Withdrawal Symptoms:

_______ Tremors ______ Depressed Mood ________ Sweating _______ Headache ______ Weakness ________ Agitation

_______ Dehydration ______ Nausea ________Anxiety _______ Insomnia ______ Hallucination ________ Liability

_______ Substance is taken to relieve or avoid withdrawal symptoms

Other _______________

______ Substance is often taken in larger amounts or a longer period of time.______ Persistent desire or unsuccessful efforts to cut down or control substance use.______ Great deal of time spent in activities necessary to obtain the substance.______Import social, occupational, or recreational activities give up or reduced because of

substance use.______Continued substance use despite knowledge of having a persistent or recurrent physical

or psychological problem______ With Physiological dependence______ Without physiological dependence

Substance Abuse

_______ Failure to fulfill major role obligations at work, school, or home_______ Persistent social or interpersonal problems.

V- Test Results and Interpretations

(MAST)/ Alcoholism = _____ _______________________________

(RFT)/ R - RS= _____ DS = _______ ES= ________ A - RS= _____ DS = _______ ES= ________ TS - RS= _____ DS = _______ ES= ________

(A/DAT)/ Level of Addiction = _______ _______________________________(A/DSI)/ Inventory = _______ ______________________________________




Type= ________________

Smoking

Stimulation = _______Handling = _______Pleasurable Relaxation = _______Tension Reduction = _______Psychological Addiction = _______Habit = _______

Hostility

Cynicism = _______ _____________________Anger = _______ _____________________Aggression = _______ _____________________

Hostility Level = _______ _____________________

Intellectual Functioning

(Mental Aging)

Results to RPM RS = ______________IQ= ______________PR= ______________

QD= ______________________

Results to BGVMT ________ ______________________

Psychological and Emotional Functioning / (PA)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




_____________________________________________________________________________________________________________________________________________

VI- Assessment________________________________________________________________________________________________________________________________________________________________________________________________

VII- Remarks/Recommendations________________________________________________________________________________________________________________________________________________________________________________________________

VIII- Treatment Interventions

_________ Individual Psychotherapy_________ Group Therapy_________ Family Therapy_________ Educational Therapy

Other ________________

Prepared by:

FATHMA SONNAYA M. MINAGA, RPm

Psychometrician

Noted by:

DR. RAY P. SAGGE, M.D. Center Psychiatrist




PROCESS RECORDING

Name of Client: _______________________________

Date Activity Recording




PSYCHOSOCIAL INTERVENTIONSINTERVIEW GUIDE QUESTIONS

I. Significant Life Events

Ikuwento mo ang mga nagyari sa buhay mo …. yung ,agenda at hindi magaganda._________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

II. Significant Person

Balikan natin ang mga tao sa buhay mo. Sino-sino ang mga taong may kinalaman sa buhay mo? Anong masabi mo tungkol sa kanya? Anong nagging papel niya sa buhay mo? Anong naibigay o naitulong niya sa iyo? Ano ang kailangan mo sa kanya? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

III. Family Members

Balikan natin ang pamilya mo. Anong masasabi mo tungkol sa pamilya mo? Balikan natin ang mga tao sa pamilya mo. Sino-sino ang nasa pamilya mo? Itong si _________ anong ginawa niya? Ano ang papel nya sa pamilya? Sino ang pinakagusto mo sa pamilya? Bakit? Sinong pinakaayaw mo? Anong pinaka gustong nangyari o ginawa ng pamilya mo? Anong pinaka ayaw mong nangyari o ginagawa ng pamilya mo? Kung may kapangyarihan kang baguhin ang pamilya mo, ano ang babaguhin mo? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IV. Self Description (ask the child to draw self)

Itong si ____________________ ano naman ang mga katangian niya? …. Yung magaganda tungkol sa kanya? Anonng klasing tao siya? Saan ka magaling? _____________________________________________________________________




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V. Wishes

Ano ba ang mga gusto mo sanang mangyari sa buhay mo? Ano ba ang pangarap mo? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VI. Experience of Sexual Abuse

Balikan natin yung mga karanasan mo sa sex. Alam mo, minsan, sa buhay ng isang bata, may mga batang nagkakaroon ng karanansan; na may taong lumapit sa kanila, hinawakan sila o niyakap, o hinalikan sila, o sumobok na galawin sila. May nangyari din ba sa iyong parang ganito? Anong pakiramdam mo noong nangyari “yon”, Naaalala o naisip mo pa iyon paminsa-minsan? Gaano kadalas? Anong nararamdaman mo noong kapag naaaalala mo iyon? Anong nangyayari sa ‘yo? Anong ginawa? Sa palagay mo, anong epekto nito sa ‘yo? Anong pinakamalaking epekto nito sa buhay mo? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VII. God

Ano ba ang tingin mo sa Diyos, ano ba Siya sa buhay mo?Bakit mo nasabi iyon? Nagdasal ka ba? Anong sinasabi mo kapag nagdadasal ka? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VIII. Friends

May mga kaibigan ka ba? Sino? Sino’ng pinakamatalik mong kaibigan? Sino naman ang kaaway mo/pinakaayaw mong kasama? Bakit? Ano ang gingawa nyo kapag magkasama kayo? Anong pinakagusto mo sa kanya? _____________________________________________________________________




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IX. Lovelife

Nagka girlfriend ka na ba? Ikuwento mo naman. Bakit paano mo siya naging girlfriend? Gusto mo bang magka girlfriend? Bakit/Bakit hindi? Anong klaseng tao ang gusto mong maging girlfriend? Gusto mo bang makapag-asawa? Bakit/ Bakit hindi? Anong klaseng tao ang gusto maging asawa? Maliban sa nagging karanasan mo na …… (Sexual abuse). Nagkaroon ka na ba ng karanasan sa nagging girlfriend mo, o sa ibang tao? Ano ang tingin mo sa sex ngayon; pakiramdam mo, ano ang nagging papel mo nito sa buhay mo ngayon? Ano ba ang pag-ibig o pagmamahal, ano ba ang pakiramdam noon? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

X. Rehabilitation

Anong pinakagusto mong ginawa mo ditto sa center? Bakit? Sino’ng pinaka-importante sa iyo ditto sa center? Sino’ng pinaka-ayaw mo? Bakit? May pagbabago ba ang buhay mo mula nang dumating ka dito sa center? Anu-ano yon? Alin ang pinakagusto mong pagbabaago sa iyo? Bakit? Lumayas ka na ba minsan? Kailan? Bakit? Bakit ka bumalik? Bakit ka nagtatagal dito? Ano ang puwedeng mangyari na maiisipan mong umalis/pumuga na hindi ka na babalik? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

XI. Coping

Sa sarili mo naman, anong pinakaayaw mong nangyari sa araw- araw mong buhay? Anong ginagawa mo sa mga ganoong panahon/pangyayari? Sa mga ginagawa mong ito, alin ang pinaka- nakatutulong? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




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Personal Data Sheet

________________________________________________ Sex _______ Age ______(Family name) (First Name) (M.I.)Date of Birth: __________ Place of Birth __________________________ Religion:____________Complete Home Address: _______________________________________________________________________________________________________________ tel/cell #:________________Are you living with parent’s? Yes _____ No _____ If no, with whom? ______________________Address: ______________________________________________________________________Name of Parents Religion Educational Attainment OccupationFather: ___________________ ___________ ___________________ ____________Mother: __________________ ___________ ___________________ ____________Guardian: _________________ ___________ ___________________ ____________# of Brothers _______ # of Sisters _______Names of Brother and Sisters from the oldest to the youngest:Include yourself Age Age1. ________________________ _______ 6. ________________________ ________2. ________________________ _______ 7. ________________________ ________3. ________________________ _______ 8. ________________________ ________4. ________________________ _______ 9. ________________________ ________5. ________________________ _______ 10. ________________________ ________

How do you consider your family? Very rich __ Rich ___Average ___Poor ___ Very Poor __________________________________________________________________________________List the school you have attended and indicate your grade:

School Grade________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Were you an honor student? Yes _____ or No ______Do you have a failing mark? Yes ______ or no _____ if yes, what subjects? ______________________________________________________________________________Nature of Schooling: Continuous ______ Interrupted _______ if interrupted, why?______________________________________________________________________________Name/s of your best friends? ______________________________________________________




List the names of organization/s, which you are a member: ____________________________________________________________________________________________________________________________________________________________Hobbies: ______________________________________________________________________Ambition: _____________________________________________________________________

Substance use History: Substance Age of Why Began Frequency How Taken Quantity Date Last Use

1st Use Amount Spent/Week

Documents

Psychological test batteries