As you begin treatment, it is important that you think carefully about what you want from it. You may want to change some of your behaviors or solve some of your personal problems. To help you get your treatment goals clearly in mind and to help us work with you towards achieving these goals, please answer this short form.

Read each of the statements listed below and on the back of the page. If it is an important problem for you, please circle the number beside it. IF it is not important right now, you may leave it blank and return to it later if you wish.
1. Learning how to ask for help so that I can avoid feeling overwhelmed.
2. Learning how to say “no” without feeling guilty, uncomfortable, or fearful.
3. Getting along with people better.
4. Improving relationships with my family (spouse, parents, siblings, etc.).
5. Avoiding the use of alcohol and/or drugs.
6. Learning how to care for my children better.
7. Learning ow to plan and cook better meals.
8. Learning how to manage my money.
9. Learning my relapse triggers and what makes me want to use drugs and/or drink alcohol.
10. Maintaining good hygiene and a better personal appearance.
11. Using my leisure time better.
12. Learning how to make and keep healthy friends that will support me, my goals and my overall recovery.
13. Learning how to have fun without drugs and/or alcohol.
14. Learning how to express my anger in a healthy, constructive way.
15. Controlling my temper.
16. Learning how to express my ideas clearly and effectively to others.
17. Avoid8ing the feeling that everything must be perfect.
18. Learning how to slowly trust others and have them trust me.
19. Ending abuse or violence in my relationships.
20. Working on my unresolved guilt feelings.
21. Rebuilding my faith or getting back to church or spiritual practices.
22. Overcoming my shyness.
23. Learning how to avoid feeling loneliness, isolation, and/or withdrawing from others.
24. Getting rid of imaginary voices or visions.
25. Learning how to concentrate better
26. Learning how to express my real feelings without feeling “choked p”, anxious and/or ashamed.
27. Learning how to worry less and enjoy the ‘here and now’.
28. Feeling more cheerful and hopeful about things (and my life).
29. Feeling better physically.
30. Learning how to love and care for myself.
31. Overcoming problems with sexual functioning.
32. Feeling more self-confident.
33. Increasing my self-respect and respect of others.
34. Avoid being around alcohol and/or drug using friends & peers.
35. Learning how to control my behaviors & to avoid future trouble/involvements with the law.
36. Learning how to avoid behaviors that hurts others physically.
37. Learning how to avoid behaviors that hurts others emotionally.
38. Avoiding thoughts of wanting to hurt myself or others.
39. Learning how to get along better with my spouse/partner.
40. Learning how to get along better with my friends/family members.
41. Learning how to avoid feelings of boredom or idleness.
42. Taking care of my health problems.
43. Taking my medications as prescribes my physician.
44. Avoiding manipulative, deviant, and self-defeating behaviors
After you have selected the areas that you considered challenging and wanting to work on, select the six most important problem areas that you want to work on during your treatment. As you complete first six, you will have an opportunity to address the remaining problem areas. Enter the statement numbers of your first six problem areas in the spaces provided below.