| Change Is A Choice |
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Name_______________________________Date____________
What I Want From Treatment
Instructions: People have different ideas about what they want, need, and expect from treatment.
This questionnaire is to be filled out after your assessment has been completed. It is intended to
help you explain what you would like to have happen through your participation in treatment, and to
help design your treatment plan.
For each possibility listed below, please indicate how much you would like it to be part of your
treatment. Do this by putting a big X in one of the columns. This is what the columns mean:
NO means you definitely do NOT want or need this from treatment.
MAYBE means you are UNSURE. MAYBE you want or need this from treatment.
YES means you DO want or need this from treatment.
YES! ` means you DEFINITELY want or need this from treatment.
If you have questions about how to use this questionnaire, ask for assistance before you begin.
(ASAM: Intoxication and withdrawal)
I. Do you want this from treatment? NO MAYBE YES YES!
1. I want to receive detoxification, to ease my withdrawal from alcohol or other
drugs.
2. I want to take methadone instead of heroin.
3. I worry that if I stop drinking or using other drugs, I will feel awful: I want to be able to get
help with this.
(ASAM: Biomedical conditions)
II. Do you want this from treatment? NO MAYBE YES YES!
1. I want help with some health problems.
2. I would like to improve my health by learning more about nutrition.
3. I would like to learn more about exercise.
4. I would like testing for HIV/AIDS.
5. I would like help avoiding infection from HIV and other dangerous diseases.
6. I want to see a doctor or nurse about some health problems.
7. I want to receive medication for health problems.
8. I want information about how alcohol or drugs affect my health problems.
9. I want help with sleep problems.
10. I want help taking better care of my appearance.
(ASAM: Emotional, behavioral, cognitive conditions)
III. Do you want this from treatment? NO MAYBE YES YES!
1. I want help making the voices that I hear go away.
2. I would like to discuss my suicidal thoughts.
3. I would like help with my feelings of confusion.
4. I want help with personal fears and anxieties.
5. I want help with depression or moodiness.
6. I want help to decrease my stress and tension.
7. Someone close to me has died or left, and I would like to talk about it.
8. I want someone to listen to me.
9. I want help with angry feelings and how I express them.
10. I would like to discuss sexual problems.
11. I want to discuss having been physically abused.
12. I want to discuss having been sexually abused.
13. I want information about how alcohol or drugs affect my mental health
problems.
14. I want help understanding why I need to take medications.
15. I want different medications that will make me feel better.
16. I want to feel better about myself and have higher self-esteem
(ASAM: Readiness to change)
IV. Do you want this from treatment? NO MAYBE YES YES!
1. I want to stop drinking alcohol completely.
2. I want to decrease my drinking.
3. I want to stop using drugs (other than alcohol) completely.
4. I want to decrease my use of drugs (other than alcohol).
5. I want to learn how to use alcohol safely.
6. I want to learn how to use drugs safely.
7. I want to learn more about alcohol and drug problems.
(ASAM: Continued problem potential)
V. Do you want this from treatment? NO MAYBE YES YES!
1. I want help understanding why I keep using alcohol or other drugs, even though I want to cut
down or stop.
2. I want help finding other activities I can do instead of using alcohol or other
drugs.
3. I want help finding other support systems to help me with my life.
4. I want to learn some skills to keep from returning to alcohol or other drugs.
5. I would like to learn more about 12-step programs like Alcoholics Anonymous (AA), Narcotics
Anonymous (NA), or Dual Diagnosis Anonymous.
(ASAM: Recovery environment)
VI. Do you want this from treatment? NO MAYBE YES YES!
1. I am homeless and want help finding a place to live.
2. I’m not homeless now, but want help finding a better place to live.
3. I want help making sure I do whatever I need to in order to stay housed where I
am.
4. I want help with improving my relationships with family members (parents, brothers or sisters,
spouse, children).
5. I want my family or partner involved in my treatment.
6. I want to have healthier, more supportive relationships.
7. I want to improve my skills for handling annoying people.
8. I want help resolving some legal problems.
9. I want help avoiding problems with the police.
10. I need to fulfill a requirement of the courts.
11. I want help with my financial situation.
12. I want to find out what benefits I may be eligible for.
13. I want to work on my spiritual growth.
14. I could use help finding a job.
15. I would like to develop some job skills.
16. I want more structure and focus in my life.
What I Want From Treatment
Instructions: People have different ideas about what they want, need, and expect from treatment.
This questionnaire is to be filled out after your assessment has been completed. It is intended to
help you explain what you would like to have happen through your participation in treatment, and to
help design your treatment plan.
For each possibility listed below, please indicate how much you would like it to be part of your
treatment. Do this by putting a big X in one of the columns. This is what the columns mean:
NO means you definitely do NOT want or need this from treatment.
MAYBE means you are UNSURE. MAYBE you want or need this from treatment.
YES means you DO want or need this from treatment.
YES! ` means you DEFINITELY want or need this from treatment.
If you have questions about how to use this questionnaire, ask for assistance before you begin.
(ASAM: Intoxication and withdrawal)
I. Do you want this from treatment? NO MAYBE YES YES!
1. I want to receive detoxification, to ease my withdrawal from alcohol or other
drugs.
2. I want to take methadone instead of heroin.
3. I worry that if I stop drinking or using other drugs, I will feel awful: I want to be able to get
help with this.
(ASAM: Biomedical conditions)
II. Do you want this from treatment? NO MAYBE YES YES!
1. I want help with some health problems.
2. I would like to improve my health by learning more about nutrition.
3. I would like to learn more about exercise.
4. I would like testing for HIV/AIDS.
5. I would like help avoiding infection from HIV and other dangerous diseases.
6. I want to see a doctor or nurse about some health problems.
7. I want to receive medication for health problems.
8. I want information about how alcohol or drugs affect my health problems.
9. I want help with sleep problems.
10. I want help taking better care of my appearance.
(ASAM: Emotional, behavioral, cognitive conditions)
III. Do you want this from treatment? NO MAYBE YES YES!
1. I want help making the voices that I hear go away.
2. I would like to discuss my suicidal thoughts.
3. I would like help with my feelings of confusion.
4. I want help with personal fears and anxieties.
5. I want help with depression or moodiness.
6. I want help to decrease my stress and tension.
7. Someone close to me has died or left, and I would like to talk about it.
8. I want someone to listen to me.
9. I want help with angry feelings and how I express them.
10. I would like to discuss sexual problems.
11. I want to discuss having been physically abused.
12. I want to discuss having been sexually abused.
13. I want information about how alcohol or drugs affect my mental health
problems.
14. I want help understanding why I need to take medications.
15. I want different medications that will make me feel better.
16. I want to feel better about myself and have higher self-esteem
(ASAM: Readiness to change)
IV. Do you want this from treatment? NO MAYBE YES YES!
1. I want to stop drinking alcohol completely.
2. I want to decrease my drinking.
3. I want to stop using drugs (other than alcohol) completely.
4. I want to decrease my use of drugs (other than alcohol).
5. I want to learn how to use alcohol safely.
6. I want to learn how to use drugs safely.
7. I want to learn more about alcohol and drug problems.
(ASAM: Continued problem potential)
V. Do you want this from treatment? NO MAYBE YES YES!
1. I want help understanding why I keep using alcohol or other drugs, even though I want to cut
down or stop.
2. I want help finding other activities I can do instead of using alcohol or other
drugs.
3. I want help finding other support systems to help me with my life.
4. I want to learn some skills to keep from returning to alcohol or other drugs.
5. I would like to learn more about 12-step programs like Alcoholics Anonymous (AA), Narcotics
Anonymous (NA), or Dual Diagnosis Anonymous.
(ASAM: Recovery environment)
VI. Do you want this from treatment? NO MAYBE YES YES!
1. I am homeless and want help finding a place to live.
2. I’m not homeless now, but want help finding a better place to live.
3. I want help making sure I do whatever I need to in order to stay housed where I
am.
4. I want help with improving my relationships with family members (parents, brothers or sisters,
spouse, children).
5. I want my family or partner involved in my treatment.
6. I want to have healthier, more supportive relationships.
7. I want to improve my skills for handling annoying people.
8. I want help resolving some legal problems.
9. I want help avoiding problems with the police.
10. I need to fulfill a requirement of the courts.
11. I want help with my financial situation.
12. I want to find out what benefits I may be eligible for.
13. I want to work on my spiritual growth.
14. I could use help finding a job.
15. I would like to develop some job skills.
16. I want more structure and focus in my life.