0 - National Criminal Justice Reference Service

EVALUATION OF SELF AND TREATMENT
INSTRUCTIONS:
1. PIease do /Jot write or mark airytlring 011 this questionnaire booklet. Instead, please answer all questions on the red
scantron, using a pencil (not a pen). On the left hand side of the red scantron, please provide the following information.
2.
3.
4.
5.
6.
7.
LAST NAME, FIRST NAME, AND MIDDLE INITIAL: please print in the white squares, then darken in the
corresponding circles right underneath.
DATE (MONTH, DAY, YEAR): please circle the appropriate month. Then print the day and the year in the white
squares, and darken the corresponding circles right underneath.
IDENTIFICATION NUMBER: please print your irrmate number in the white squares, then darken in the corresponding
circles right underneath.
SPECIAL CODE ‘J? please enter the assigned number for your institution:
1 = CRESSON 2 = GRATERFORD 3 = HOUTZDALE 4 = HUNTMGDON 5 = WAYMART
SPECIAL CODE ‘Kt: please enter the type of D & A program you are currently in:
1= EDUCATION 2 = OUTPATIENT TREATMENT 3 = THERAPEUTIC COMMUNITY
Please answer each question by darkening the appropriate circle on the red scantron. Refer to the Fpoint scale on your
questionnaire booklet (e.g., 1 = “disagree strongly”; 7 = “agree strongly”). Please answer all questions the best you can.
8.
-
Your answers are confidential. When you are done, please insert the red scantron in the envelope provided, seal it, and rc .Jm it
to your counselor. Please hand in the questionnaire booklet separately.
A. RATINGS OF SELF: Circle the answer that shows how much you agree or disagree
that each item describes you or the way you have been feeling lately.
DISAGREE NOT AGRElE
STRONGLY ........... SURE ......... .STRONGLY
1. You like to take chances .............................................. 1 2 3 4 5 6 7
2. You feel people are important to you .......................... 1 2 3 4 5 6 7
3. You feel sad or depressed ............................................ 1 2 3 4 5 6 7
4. You feel honesty is required in every situation ............. 1 2 3 4 5 6 7
5. You have serious drug-related health problems ............ 1 2 3 4 5 6 7
6. You have little control over the things that happen to
you .............................................................................. 1 2 3 4 5 6 7
7. You have too many outside responsibilities now to be
in this treatment program ............................................. 1 2 3 4 5 6 7
8. You have much to be proud of ...................................... 1 2 3 4 5 6 7
....................
9. In general, you are satisfied with yourself 1 2 3 4 5 6 7
10. You like the “fast” life ................................................... 1 2 3 4 5 6 7
11. There is really no way you can solve some of the
problems you have ......................................................... 1 2 3 4 5 6 7
I 1
Continue to Next Page
Page 1 of 7
This document is a research report submitted to the U.S. Department of Justice. This report has not
been published by the Department. Opinions or points of view expressed are those of the author(s)
and do not necessarily reflect the official position or policies of the U.S. Department of Justice.