Chemical Dependency Assessment Form

CHEMICAL DEPENDENCY ASSESSMENT FORM

  • EASILY AGITATED? EXTREMELY DEFENSIVE?
  • DEFIANT WHEN QUESTIONED OR CHALLENGED ABOUT GENERAL QUESTIONING?
  • ENTITLED?
  • PROBLEMS WITH IMPULSE CONTROL?
  • ISOLATING?
  • EXHIBITING RAGE OR INORDINATE ANGER?
  • SUDDENLY STRUGGLING ACADEMICALLY?
  • EXPERIENCING RAPID WEIGHT LOSS OR GAIN?
  • MISSING PRACTICE, WORK, AND COMMITMENTS OFTEN?
  • DISAPPEARING DURING PRACTICE OR WORK OFTEN, TO THE LOCKER ROOM OR RESTROOM?
  • RUMORED TO BE PARTYING EXCESSIVELY?
  • HAVING EXCESSIVE RELATIONSHIP ISSUES?
  • EXPERIENCING LEGAL ISSUES?
  • BLAMING OTHER PEOPLE, PLACES AND THINGS FOR THE WAY THEIR LIFE IS?

ONCE YOU HAVE DETERMINED THERE MIGHT BE A SUBSTANCE ABUSE ISSUE, LOOK FOR THE FOLLOWING SYMPTOMS

Alcohol Abuse
Anxiety or Jumpiness
Sweating excessively
Nausea or Vomiting
Tremors
Fatigue
Irritability
Depression or frequent sadness
Marijuana Abuse
Lethargy
Red Eyes
Paranoia
Mood Swings
Panic Attacks
confusion or psychosis

PARAPHERNALIA: rolling papers, small plastic baggies and stash cans (film canisters, small glass vials, mint tins), pipes, bongs, roach clips, room deodorizers and incense.

Opiate Abuse
Withdraw symptoms occur every few hours unless drug is accessible. They include:
Dehydration
Irritability
Rage
Sweating
Vomiting
Diarrhea
inability to be still
severe pain in legs

PARAPHERNALIA: needles, Rx Pill bottles, or supplement bottles, small pieces of crumpled foil (usually with black burn marks), empty heroin “balloons”

Steroid Abuse
Rapid Muscle Gain
Uncontrolled aggression and violent behavior
Mood Swings
Sense of invincibility (may even be associated with delusions)
Paranoid Jealousy
Hair Loss

PARAPHERNALIA: needles, creams and ointments, supplement bottles

Stimulant Abuse
Manic Behavior. Inability to sit still
“Chewing” inner jaw
Runny Nose, chronic cold or sinus problems
nose bleeds
dry mouth or chapped lips
bad breath
rapid weight loss (associated with loss of interest in food or sleep)
excessive talking-changing subjects frequently
Irritable or Argumentative
Nervous

PARAPHERNALIA: small spoons, razor blades, mirror, little bottles of white powder, and plastic metal or glass straws.