Counselor's Manual for Relapse Prevention With Chemically ...

1. I stopped using on ____________________________(month and year).2. I stayed completely clean and sober for ________________ (days, weeks, months, and/oryears).3. When I stopped using alcohol/drugs, I used the following help:A. AA/NA. Meetings per week ._____B. Sponsor. I talked to my sponsor ______ times (fill in number of times per week).C. Worked on steps: 1 2 3 4 5 6 7 8 9 10 11 12 noneD. Detox. Number of days _____.E. Outpatient counseling. Number of times per month _____.F. Inpatient program. Length of inpatient time _______.G. Prescribed medications ________________________________4. How did you feel during this time? (check one). I never felt good or calm.A. I felt good once in a while, but it didn't last.B. I felt good most of the time, but sometimes I felt awful.C. I always felt good and thought I could do well.5. I had problems during this period of not using..A.B.C.D.E.F.G.H.I.J.K.L.M.N.O.I had the following problems with people. Example: I fought with my wife.I had the following problems with situations. Example: I lived in a place where therewere drug dealers.I had the following problems with thoughts and feelings. Example: I was angry andcouldn't seem to think about anything but using alcohol or drugs.I had the following problems with pain and sickness. Example: My back hurt and I wastired all the time.