SAQ-Adult Probation III

Transcription

1 SAQ-Adult Probation III Instructions The statements in this booklet are numbered. Match the number of the statement with the number on your answer sheet. All statements must be answered. Your records may be reviewed to verify the information you provide. Drinking refers to beer, wine or liquor. Drugs refer to marijuana, amphetamines, barbiturates, crack, cocaine and heroin. DO NOT MAKE ANY MARKS ON THIS BOOKLET Section 1 Answer the following statements True or False. If a statement is True put an X under T for True. If a statement is False put an X under F for False. 1. Sometimes I worry about what others think or say about me. 2. I am concerned about my drinking. 3. I am too aggressive and outspoken. 4. There are times when I get so angry I cannot control myself. 5. There have been times when I have felt guilty about using drugs. 6. As a youth I often lied, stole things and skipped school. 7. There are times when I get very discouraged. 8. I have been told I have a drinking problem. 9. I often do or say things before thinking. 10. If someone hurts or insults me, I usually try to get even. 11. I have gone to Narcotics Anonymous (NA) or Cocaine Anonymous (CA) meetings for help with my drug use. 12. People tell me I am unsociable because I avoid being close to most people. 13. It bothers me when people I know overlook or ignore me. 14. I lose my temper very quickly. 15. I often have problems getting along with others. 16. Most people irritate or annoy me. 17. There are times when I am very unhappy. 18. My drinking is more than just a little or minor problem. 19. When angry I often fly off the handle and lash out at others. 20. When I get very angry I yell and often throw or break things. 21. I have used drugs more than I should. 22. I wish people would leave me alone and let me deal with my own problems. 23. Sometimes I really worry about my responsibilities and happiness. 24. Two or more of the following apply to me a. Daring or fearless b. Adventurous or outgoing c. Disruptive or argumentative d. Outspoken or quick tempered e. Thin skinned, touchy or sensitive 25. I can be dangerous when frustrated, insulted or angered. 26. People often think I am antisocial because I am unfriendly, unsociable and sometimes hostile. 27. There have been times when I have been jealous or resentful of others. 28. In the last year, drinking has been a problem for me. 29. I am easily annoyed or angered. 30. People tell me I have a quick temper and a bad attitude. 31. I have been told I have a drug problem. 32. To be honest, I will manipulate and lie to get what I want. 33. There are times when I worry about my life and my future. 34. People tell me I am too aggressive.

2 35. Two or more of the following apply to me a. Brutal or threatening b. Explosive or dangerous c. Uncontrollable or cruel d. Fighting or argumentative e. Vengeful or carry a grudge 36. I do not know why, but I seem to keep getting into trouble with the law. 37. Sometimes I get angry or upset at myself. 38. I have lied to people about my drinking -- either minimizing how much I drink or hiding the fact that I drink at all. 39. When annoyed or angry I can be verbally abusive. 40. I have been cruel to someone and deliberately hurt them. 41. My use of drugs has threatened my happiness and success in life. 42. Two or more of the following apply to me a. I have a poor job or work history b. I am boastful, irritable or demanding c. I am not usually grateful or thankful d. I am often late in paying bills or loans e. I have a poor job performance record 43. I have done things when mad or angry that I regret. 44. I have a drinking or alcohol-related problem. 45. I have a quick temper and need to learn how to control it. 46. I am more destructive or dangerous than others my age. 47. I have tried to cut down or stop using drugs, but I still use them. 48. Two or more of the following apply to me a. I often lie or steal b. I am secretive or sneaky c. I am unreliable or untrustworthy d. I have alcohol or drug problems e. I have frequent problems with the law 49. I worry about how others will react to my court record or my having been on probation. 50. I need help to stop drinking. 51. I know I am too pushy and aggressive. 52. I am often angry or upset. 53. I have been treated for a drug problem. 54. Anything I do is okay, as long as I do not get caught. 55. There have been times when I have had a job but did not want to go to work. 56. This last year my family has complained to me about my drinking. 57. I am often loud and disruptive. 58. I am a violent person. 59. I am moody, irritable and demanding. 60. There are times when I am really depressed. 61. People tell me I get angry too quickly. 62. When angry I can be dangerous. 63. In the last year, using drugs has been a problem for me. 64. People tell me I am antisocial because they say many of my ideas could be harmful to others. 65. I am concerned that others may think badly of me. 66. I have asked for help with my drinking problem. 67. Two or more of the following apply to me a. I speak my mind b. I am forceful and persistent c. I am bold and get in your face d. I snap back and argue a lot e. I dominate and intimidate others 68. I have been arrested for assault or a violent crime. 69. I can handle my own problems and do not want or need help. 70. I have been embarrassed and worried about mistakes I have made. 71. My drinking is a serious problem. 72. I am full of energy and can be unruly or disruptive. 73. I have deliberately hurt or threatened to hurt someone. 74. I have gone to someone for help about my drug problem. 75. Many of my ideas could be harmful to others.

3 76. Sometimes I get frustrated and very angry. 77. I have been treated for a drinking problem. 78. When angry I shout and swear a lot. 79. I have a short temper and can get very angry quickly. 80. I do a lot of unnecessary or needless lying and conning of others. 81. I do not always tell the whole truth when asked about my finances or personal life. 82. I get into a lot of heated discussions and arguments. 83. I often think about revenge and how I can get even. 84. I have lied to people about my use of drugs -- either minimizing how much I really use, or hiding the fact that I use drugs at all. 85. It is difficult for me to keep close, lasting and warm relationships. 86. There are times when I daydream about being rich or famous. 87. I have been told I am an alcoholic. 88. I show my frustration and anger quickly. 89. I often think about death, dying or suicide. 90. I have a drug abuse or drug-related problem. 91. I have done things that were wrong and I was not caught. 92. I am very vocal, often interrupt and like to speak my mind. 93. I am often suspicious and distrustful of others. 94. There are times when I am really down, depressed and discouraged. 95. I have gone to Alcoholics Anonymous (AA) meetings for help with my drinking. 96. I can be very demanding and aggressive. 97. Two or more of the following apply to me a. Cold or indifferent b. Lying or manipulative c. Harassing or threatening d. Lack of remorse or regret e. Unsympathetic or uncaring 98. It upsets me when I am criticized. 99. A lot of people do not like my aggressiveness I have a lot of anger, resentment and hostility toward others I am in treatment for a drug problem I am outgoing and outspoken People tell me I am a selfish and ungrateful person I am dependent on drugs and may be addicted to them I am a non-violent person To be honest, I should tone down my aggressiveness There are times when I worry about court, jail or probation I have been told I am a cold, selfish and ungrateful person. Section 2 Rate how you feel about yourself. Put an X under the number (1, 2, 3 or 4) that applies to you now. Use the following rating scale. 1. Rare or Never 3. Often 2. Sometimes 4. Very Often or Always 109. Positive Attitude / Outlook 110. Dissatisfied with Life 111. Good Sense of Humor / Laugh 112. Anxious / Worried / Fearful 113. Depressed / Discouraged 114. Insomnia / Trouble Sleeping 115. Satisfied with Self / Like Self 116. Financially Stable / Responsible 117. Enthusiastic / Involved with Life 118. Tension / Stress / Nervous 119. Fatigued / Tired / Sluggish 120. Directly Deal with Problems 121. Emotionally Upset / Crying 122. Angry / Hostile with Others 123. Lonely / Unhappy 124. Able to Handle Life s Problems 125. Nervous / Unable to Relax

4 Section 2, continued 126. Patient / Tolerant / Understanding 127. Can t Make Decisions / Indecisive 128. Work / Job Satisfaction 129. Admit My Errors / Mistakes 130. Bored / Restless / Uninterested 131. Accept Constructive Suggestions 132. Trust My Own Judgment 133. Difficulty with Others / Conflict 134. Adaptable / Adjustable 135. Marital / Family Problems 136. Self-Reliant / Independent 137. Manipulating / Conning / Lying 138. Loss of Control / Explode / Blow-Up 139. Unsocial / Hostile / Antisocial Section 3 Put an X under the number (1, 2, 3 or 4) that is accurate for you now How would you describe your drinking? 1. Serious problem 2. Moderate problem 3. Mild or slight problem 4. No problem 141. How much motivation or desire do you have for alcohol treatment or help? 1. I want help 2. I am willing to accept help 3. I am undecided 4. There is no problem or need 142. How many different alcohol treatment programs have you been in? 1. One 2. Two or three 3. Four or more 4. None 143. How would you describe your present situation? I have serious: 1. Family problems 2. Marital or relationship problems 3. Both 1 and 2 ( family and relationship problems) 144. I have been arrested for: 1. A violent crime 2. A crime involving force or the threat of force 3. Both 1 and During the last six months I have been: 1. Dangerous to myself (suicidal) 2. Dangerous to others (homicidal) 3. Both 1 and 2 (suicidal and homicidal) 146. How would you describe your drug use? 1. Serious problem 2. Moderate problem 3. Mild or slight problem 4. No problem 147. How much motivation or desire do you have for drug treatment or help? 1. I want help 2. I am willing to accept help 3. I am undecided 4. There is no problem or need 148. How many different drug treatment programs have you been in? 1. One 2. Two or three 3. Four or more 4. None 149. Recovering means having an alcohol or drug problem, but not using or abusing anymore. I am a recovering: 1. Alcoholic 2. Drug abuser 3. Both 1 and 2 * * * * * * * CHECK TO BE SURE YOU ANSWERED ALL ITEMS. TURN IN YOUR BOOKLET AND ANSWER SHEET. THANK YOU FOR YOUR COOPERATION.

5 SAQ-Adult Probation III ANSWER SHEET First Name: Last Name: Middle Initial: Last Four Digits of Your SSN: Age: Sex: Ethnicity (Race): Education (highest grade completed): Marital Status: Single, Married, Separated, Divorced, Widowed Date of Birth: / / Month Day Year Complete the following information. Number refers to the total number in your lifetime. 1. Your age at your first arrest: 2. Number of felony arrests: 3. Number of times on probation: 4. Number of probation revocations: 5. Total number of times arrested: 6. Number of times sentenced to jail: 7. Number of times sentenced to prison: 8. Number of alcohol-related arrests: 9. Number of drug-related arrests: 10. Number of months employed in last 12 months: Section 1 Answer the following statements True or False. If a statement is True put an X under T for True. If a statement is False put an X under F for False. T F T F

6 Section 1, continued T F T F Section 2 Rate yourself by putting an X under the number (1, 2, 3 or 4) that applies to you now. Use the following rating scale. 1. Rare or Never 3. Often 2. Sometimes 4. Very Often or Always Section 2, continued Section 3 Put an X under the number (1, 2, 3 or 4) that is accurate for you now v4.01