NEEDS Survey. # Alcohol/Drug Arrests # of Misdemeanor Convictions (Lifetime)

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1 NEEDS Survey ENGLISH OFFICIAL USE DATA A (Pertains to Substance Use/Abuse only) Most Recent BAC # of Traffic Tickets OFFICIAL USE DATA B (Pertains to matters other than Substance Use/Abuse only) Do NOT include any items already reported in Official Use Data A (Last 5 Years) # Alcohol/Drug Arrests # of Misdemeanor Convictions (Lifetime) # Inpatient Sub. Abuse Treatments # of Felony Convictions (Lifetime) # Outpatient Sub. Abuse Treatments # of Revocations (Probation/Parole) (Lifetime) # Medical Sub. Abuse Detox # of Supervised Probation/Parole (Lifetime) In controlled environment at the time of this survey? # of Incarcerations (Lifetime) 0= No 1= Hospital 2= Jail/Prison 3= Other Number of days in controlled environment at the time of this survey 1 = 1-15 days 5 = days 2 = days 6 = 1-2 years 3 = days 7 = 2 + years 4 = days START TIME: FINISH TIME: Number of minutes (Round to the nearest minute) INSTRUCTIONS: Please read and answer all of the following questions. Honestly answer each question as you think it applies to you. Do not spend too much time on any one question. A single answer by itself is not as important as all your answers taken together. Complete the information below and then go to question one (1). IMPORTANT: If you are currently in a hospital, treatment center or jail/prison, or just recently discharged from one, answer these questions based on your situation before you went into the facility. Last Name: First Name: M.I.: ID Number: Date of Birth: Age: Sex: Years of School: Race: Minutes: Today s Date: 1. White 2. African American 3. Hispanic 4. Native American 5. Asian 6. Multi-Racial/Other 7. Refused

2 1. What is your current marital status? Married 2. Divorced/Remarried 3. Divorced/Living Together 4. Living Together 5. Separated 6. Divorced 7. Widowed 8. Never married 2. Using the scale below, where 1 is the very worst and 9 is the very best, select the number 2. that best reflects your feelings about your marital status you selected in the last question. 3. If you are married or living with someone, how many years have you been in this relationship? 3. If you are divorced, separated or a widow/widower, how many years have you been divorced, separated or widow/widower, etc? 4. How many dependent children do you have? What is your current primary employment status? Employed 2. Employed part-time 3. Student/employed 4. Unemployed 5. Homemaker 6. Retired 7. Student 8. Disabled 9. Migrant worker 10. Military 6. Using the scale below, where 1 is the very worst and 9 is the very best, select the number 6. that best reflects your feelings about the employment status you selected in the last question. 7. During the past year, how many months did you work full time? During the past year, how many days did you miss work, school, or were unable to function 8. because of illness? (If more than 99, write 99.) 9. During the past year, how many months did you NOT work full time? Select the item that represents the amount of money or income that you earn or contribute 10. to your living expenses. 1. All of the money 2. Most of the money 3. About half the money 4. Less than half the money 5. None 11. What is your current income level? $0-10, $10,001-20, $20,001-30, $30,001-40, $40,001-50, $50,001 or more

3 12. Have you had any special job or vocational training outside of school? 12. Y N 13. Are you unable to provide for yourself because of illness or physical handicap? 13. Y N 14. Are you under a doctor s care now? 14. Y N 15. Have you ever been in treatment or counseling for emotional problems? 15. Y N 16. Have you ever been hospitalized for emotional problems? 16. Y N 17. Solve this problem: =? How many times have you been convicted for assault? Have you ever had continuous or persistent thoughts, impulses or images that were intrusive; 19. Y N would not go away? 20. Are you always a good listener no matter whom you are talking to? 20. Y N 21. Pick the number that best represents how you feel about your physical health Does the sign No Turn on Red mean you must wait for the green light before turning? 22. Y N 23. Compared to what you think most people consider to be average, do you drink more than 23. Y N an average drinker? 24. Have you ever tried social drugs, Pot, Cocaine, etc., or street drugs? 24. Y N (do not include alcohol) 25. Has your doctor prescribed medication to help you relax? 25. Y N 26. Do people think of you as someone who can drink a lot without getting drunk? 26. Y N 27. Do you usually have a drink or two before going to social gatherings to help get into the mood 27. Y N or relax? 28. For a typical week, how many days would you have a least one drink? Pick the number that best represents how you feel about your social life during the past six 29. months. 30. In the past two years, have you tried social drugs, Pot, Cocaine, etc., or street drugs? 30. Y N (do not include alcohol) 31. Would you say that drug use keeps or has kept you from being as effective as you would like? 31. Y N (do not include alcohol)

4 32. Do you sometimes get upset by people who ask favors of you? 32. Y N 33. Are your table manners at home as good as when you eat out in a restaurant? 33. Y N 34. Would you say that you have drunk three bottles of wine (not wine coolers ), or twenty bottles 34. Y N of beer, or a fifth of liquor (whiskey, vodka, etc.) in one day? 35. Would you say that you usually have a drink or two whenever you are depressed? 35. Y N 36. Have you ever feared that you were going crazy or losing your mind? 36. Y N 37. Have you ever heard voices that others could not hear or seen things others could not see? 37. Y N 38. Do your thoughts ever race or go extremely fast in your mind, or have you had so much energy 38. Y N people thought you were not yourself? 39. Were you physically and/or sexually abused while you were growing up? 39. Y N 40. Have you ever tried to kill yourself? 40. Y N 41. During the past year have you ever lost your temper and got into a fight where you hit someone? 41. Y N 42. Would you say that you can stop drinking after two drinks whenever you want? 42. Y N 43. When driving a car, if the traffic light over your lane stays red when on-coming traffic starts, 43. Y N should you wait until it turns green before proceeding? 44. Solve this problem: =? Pick the number that best represents how you would rate your ability to handle stress On a few occasions, have you given up doing something because you thought too little of your 46. Y N ability? 47. Have your family and/or friends ever complained about your drinking? 47. Y N 48. Have you ever knowingly said something to hurt someone's feelings? 48. Y N 49. Have you ever felt that you abused the use of prescription, or social/street type drugs? 49. Y N 50. Do you sometimes think that when people have troubles, they only got what they deserved? 50. Y N 51. Have you ever experienced a blackout while drinking - a time of drinking in which you carried 51. Y N on activities that you should have been able to remember, but were unable to?

5 52. Do you usually have a drink or two to calm down when you are angry? 52. Y N 53. Did you ever "play like you were sick" to get out of something? 53. Y N 54. Pick the number that best represents how you feel about your life at this time Do you believe that alcohol use keeps or has kept you from being as effective as you would like? 55. Y N 56. Do you feel guilty about your drinking? 56. Y N 57. Have there been times when you were quite jealous of the good fortune of others? 57. Y N 58. Before making a left hand turn at an intersection, should you yield to oncoming traffic? 58. Y N 59. Have you found that after a while, in order to get the same effects, you needed to increase the 59. Y N amount of social/street drugs you were trying? 60. Have you ever been upset when people expressed ideas very different from your own? 60. Y N 61. At times, have you really insisted on having things your own way? 61. Y N 62. How many times have you been arrested for an alcohol/drug related offense? Have you been recently depressed, or felt like life is not worth living? 63. Y N 64. How many times have you been in a treatment program for alcohol or drug problems? 64. (Do not include court ordered substance abuse education) 65. Have you ever felt the urge to tell someone off? 65. Y N 66. Did your father and/or mother treat you fairly while you were growing up? 66. Y N 67. Have there been times when you felt like disobeying people in power even though you knew 67. Y N they were right? 68. Has your drinking ever caused problems with your family or friends? 68. Y N 69. Do you find it difficult to get along with loudmouthed, bossy people? 69. Y N 70. Have you been physically and/or sexually abused during the past year? 70. Y N 71. Do you feel guilty about your use of drugs or medication? 71. Y N

6 72. Has anyone ever attended an Alanon meeting or sought counseling because of your drinking? 72. Y N 73. Have you ever attended, or thought about attending an A.A. meeting because of your drinking 73. Y N and/or N.A. because of your drug use? 74. Do you like to gossip at times? 74. Y N 75. Have you ever felt that you were punished without cause? 75. Y N 76. Do these symbols have the same meaning? 76. Y N 77. Pick the number that best represents your childhood family life For a typical week, how many days a week would you use/try some type of social or street drug? Have your family and/or friends ever complained about your use of drugs or medication? 79. Y N 80. Before voting, do you carefully investigate the background and record of each person running 80. Y N for office? 81. Have you ever intensely disliked anyone? 81. Y N 82. Has your wife/husband/friend ever threatened to leave you because of your drinking? 82. Y N 83. More than once, have you gotten violently angry while drinking or using drugs? 83. Y N 84. Have there been some occasions when you took advantage of someone? 84. Y N 85. On occasion, have you had doubts about your ability to succeed in life? 85. Y N 86. Have you ever made several attempts to stop drinking, but ended up drinking again? 86. Y N 87. Have there been times when you felt like smashing things? 87. Y N 88. Pick the number that best represents your current family life. 88. (Write a zero (0) if this does not apply to you) 89. Do you sometimes feel angry when you don't get your way? 89. Y N 90. Have you ever forgotten or overlooked your duties, family, or your work for two or more 90. Y N days in a row because of drinking or using drugs? 91. Are you always courteous, even to people who are disagreeable? 91. Y N

7 92. Have you experienced physical and emotional after-effects resulting from heavy drug use? 92. Y N 93. Do you sometimes try to get even rather than forgive and forget? 93. Y N 94. At least once, while drinking or using drugs, have you thought about killing yourself? 94. Y N 95. Have there been times when you had to hide the fact that you had been drinking? 95. Y N 96. Do you usually take medication to help you get to sleep at night? 96. Y N 97. If you could get into a movie without paying and were sure of not being seen, would you 97. Y N probably do it? 98. Do these symbols have the same meaning? 98. Y N 99. Pick the number that best represents your feelings about yourself in the past year After a night of heavy drinking, does a drink the next morning usually help get you going? 100. Y N 101. After a night of heavy drinking, the next morning do your hands noticeably shake? 101. Y N 102. Do you always admit it when you make a mistake? 102. Y N 103. Do you always practice what you preach? 103. Y N 104. Have you made several attempts to stop using drugs, but ended up using drugs again? 104. Y N 105. To avoid eye strain during a long trip, should the driver of the car move his or her eyes across 105. Y N the road frequently rather than just stare at the road ahead? 106. Has a doctor or health professional told you to stop drinking? 106. Y N 107. When driving near homes, should the driver of the car watch out for children running into 107. Y N the streets? 108. Is it sometimes hard for you to go on with your work if you are not encouraged? 108. Y N 109. Have you ever felt for no reason a sudden spell of fear or panic come over you? 109. Y N 110. Do you sometimes have a strong urge to drink or use drugs, even when you are not? 110. Y N

8 111. During the past three (3) years how many months of continuous full-time employment did you 111. have? 112. During the past year how many months were you on public assistance? 112. (Answer 0 if you were not on public assistance during this time period.) 113. How old were you when you began drinking regularly - - at least once a month? If you never 113. drank monthly, answer How old were you when you began using drugs regularly - - at least once a month? If you never 114. used drugs monthly, answer Have you ever been afraid to leave your home or to go out into public places, such as 115. Y N restaurants, malls, etc.? 116. With whom do you live now? Spouse 2. Boyfriend/Girlfriend 3. Parents 4. Mother 5. Father 6. Brother(s)/Sister(s) 7. Relatives 8. Friend(s) 9. Alone 10. Other 117. How many full time jobs have you had during the past three years? How many times have you been involved in an eviction, repossession, garnishment, or 118. bankruptcy? 119. During the past year, how many places have you lived? 119.

9 120. From the list below, select the number of the item that you have tried or used at least once. (Write each number followed by a comma, for example: 1, 2, 3) From the list below, select the number of the item that you used or tried most often during the past 121. three years When was the last time that you used this drug (the item selected in QUESTION 121)? 122. (Enter 0 if you entered 0 for question 121) 1. Today 2. Yesterday 3. Within the past week 4. Two to four weeks ago 5. One to two months ago 6. Three to six months ago 7. More than six months ago 8. More than a year ago 123. From the list below select the number of the item you used second most often during the past 123. three years When was the last time that you used this drug (the item selected in QUESTION 123)? 124. (Enter 0 if you entered 0 for Question 123) 1. Today 2. Yesterday 3. Within the past week 4. Two to Four weeks ago 5. One to Two months ago 6. Three to Six months ago 7. More than Six months ago 8. More than a year ago 0. None Choices for Questions 120, 121, and Alcohol (Includes beer, wine, wine coolers, liquor) 2. Sedatives & Hypnotics doriden, noludar, quaalude, sopor (Includes ludes) 3. Barbiturates amytal, nembutal, seconal, tuinal (Includes barbs, reds) 4. Tranquilizers librium, valium, miltown, equanil, rohypnol (Includes klonopin, xanax) 5. Heroin (Includes horse) 6. Other Narcotics opiates, codeine, oxycontin, darvon, demerol, dilaudid, morphine, opium, paregoric, percodan, talwin, methadone (Includes percs) 7. Cocaine (Includes coke, blow, toot) 8. Crack (Includes rock) 9. Amphetamines methamphetamines, speed, diet pills, MDA, Benzedrine, ice, MDMA, desoxyn, Dexedrine, preludin, Ritalin (includes crank, bennies, whites, crystal, black beauties, white crosses, mini thin, ecstacy) 10. Hallucinogens LSD, DMT, PCP, MDS, STP, mescaline, ketamine (Includes acid, microdot, window pane, blotter, GHB, shrooms, DOB) 11. Inhalants glue, gasoline, paint thinner (Includes solvents, hydrocarbons, nitrous oxide, whippets, amyl, amyl nitrite, isobutyl nitrite, poppers, snappers, rush, locker room, climax, paint, correction fluid, turpentine, toluene, sniff) 12. Marijuana hashish, THC, (Includes grass, herb, hash, pot, weed, joint, blunt, J, doobie, hemp, sinsemilla, ganja) 13. Other Drugs (Steroids, etc)

10 125. How old were you when you were first convicted of a crime? 125. (Do not include traffic violations.) 0 = no convictions 126. How many times have your parole and/or probation been revoked? Indicate the number of times you have been convicted for a felony offense (Do not include substance abuse convictions) 128. How many times have you been in jail/prison? 128. (Do not include substance abuse incarcerations.) 129. Have any of your family, brothers, sisters, or parents ever spent time in jail/prison for any crime? 129. Y N 130. This is another ratings question. Choose a number that best represents how you feel about these areas of your life at this time. Issues that are a problem you will rate with a lower number. Issues that need treatment you could rate as 1. Issues that are less of a problem in your life would receive higher rating numbers. Those that could not be any better would receive a rating of 9. Circle the number that applies to each. Very Severe Problem (Need Treatment) Not a Problem (The Best) A. Education issues B. Emotional issues C. Court/Legal issues D. Health/Medical issues E. Job issues F. Relationship/Family issues G. Substance Abuse issues (Alcohol/Drug)