This self-assessment worksheet is designed to help you evaluate your relationship with substances or behaviors that may be problematic. It is not a diagnostic tool, but rather a way to reflect on patterns and consider whether changes might be beneficial for your wellbeing.
Complete this worksheet honestly and thoughtfully. Your answers are for your personal reflection and growth.
Part 1: Substance or Behavior Identification
What substance(s) or behavior(s) are you concerned about? Check all that apply:
Part 2: Usage Patterns
Part 3: Impact Assessment
For each statement below, indicate how often it applies to you:
| Statement | Never | Rarely | Sometimes | Often | Always |
|---|---|---|---|---|---|
| I have tried to cut down or stop but found it difficult. | |||||
| I spend more time than I intend to on this substance or behavior. | |||||
| I have experienced cravings or strong urges to engage in this substance use or behavior. | |||||
| I have continued despite negative consequences in my life. | |||||
| I have neglected responsibilities because of this substance use or behavior. | |||||
| I have given up or reduced important activities because of this substance use or behavior. | |||||
| I have experienced relationship problems related to this substance use or behavior. | |||||
| I have experienced financial problems related to this substance use or behavior. | |||||
| I have experienced health problems related to this substance use or behavior. | |||||
| I have felt guilt or shame about this substance use or behavior. |
Part 4: Motivation for Change
Not important Very important
Not confident Very confident
Part 5: Reflection
Part 6: Next Steps
Based on your reflections in this assessment, what steps might you consider taking? Check all that apply: