Psychological Test Batteries

Republic of the Philippines
City of Iligan
OFFICE OF THE CITY MAYOR
Iligan City Drug Treatment and Rehabilitation Center
Sitio Fatima, Brgy. Abuno Iligan City
PERSONAL DRUG USE QUESTIONNAIRE

(SOCRATES 8D)
Please read the following statements carefully. Each one describes a way that you
might (or might not) feel about your drug use. For each statement, circle one and
only one number for every statement
Yes
Agree
Yes
Strong
ly
Agree
?
Undeci
ded
/
Unsure
3
If I dont change my drug use soon, my

problems are going to get worse.
I have already started making some
changes in my use of drugs.
I was using drugs too much at one time,
but Ive managed to change that.
Sometimes I wonder if my drug use is
hurting other people
I have drug problem
Im not just thinking about changing my

drug use; Im already doing something
about it.
I have already changed my drug use, and I
am looking for ways to keep from slipping
back to my old pattern.
I have serious problems with drugs.
Sometimes I wonder if I am in control of my

drug use.
My drug use is causing a lot of harm.
I actively do things now to cut down or stop

my use of drugs.
I want help to keep from going back to the
drug problems that I had before
I know I have a drug problem.
There are time when I wonder if I use drug

too much
I am a drug addict.
I am working hard to change my drug use
I have made some changes in my drug use;

I want some help to keep from going back
to the way I used before.
Checklist of Questionnaires
Q1
Q2
Q3
Q4
Q5
Q6
Q7
Q8
Q9
Q1
0
Q1
1
Q1
2
Q1
3
Q1
4
Q1
5
Q1
6
Q1
7
Q1
8
Q1
9
I really want to make changes in my use of

drug.
Sometimes I wonder if I am an addict.
No
Strong
ly
Disagr
ee
1
No
Disagr
ee

City of Iligan
Source:
Miller, W. R., & Tonigan, J. S. (1996). Assessing drinkers' motivation for change: The Stages of Change
Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors 10, 81-89.
DRUG SCREEN INVENTORY

Kining sumusunod na mga pangutana mahintungod kini sa imong paggamit ug droga
sulod sa miaging tuig. Pag-circle kung OO oDILI kada pangutana base kini sa imong
kaugalingong experience o kaagi sa imaging Dose (12) ka bulan.
Sa imaging Dose (12) ka bulan
1. Has your drug use affected your ability to take care of your
Responsibility?
Ang imong paggamit sa droga nakaapekto bas a imong abilidad o
kakayahan sa pag dumala sa imong responsibilidad?
O
O
D
L
2. Have you used drugs in situations where you could have been physically
hurt?
Ninggamit ba ikaw ug droga sa mga sitwasyon kung asa ikaw
napasakitan ang imong kaugalingon?
O
O
D
L
O
O
D
L
4. Have you kept using drugs even though it caused problems with family,
friends or other people?
Nagapabilin ka ba sa paggamit sa droga maski mao kini ang usa ka
hinungdan sa problema diha sa pamilya,mga amigo o sa uban tao?
O
O
D
L
5. Have you had to use larger amounts of a drug to get the same effect
before?
Ningamit ka ba ug mas dakong kantidad sa droga aron makakuha ug
parehong epekto sama sa kaniadto?
O
O
D
L
O
O
D
L
7. Have you used larger amounts of drugs or for a longer time than you
meant for?
Migamit ba ikaw ug mas dakong kantidad sa droga o para sa mas taas
nga panahon kaysa naandan?
O
O
D
L
8. Have you often wanted to cut down on your drug use, or tried to cut
down and couldnt?
Gipanapaningkamotan ba nimong maundangan ang imong paggamit sa
droga, o misulay sa pag-undang apan dili nimo mabuhat?
O
O
D
L
3. Has your drug use resulted in problems with the law?

Ang imong paggamit bas a droga maoy us aka hinungdan nga problema
sa balaod?
6. Have you experience withdrawal symptoms or used drugs to make

withdrawal symptoms go away
Nakasinato kaba ug pagkurog-kurog, pagsuka-suka ogitawag nga
withdrawal symptoms o magamit na lang sa droga aron dili ikaw
masulay sa maong mga sintomas?

City of Iligan
9. Have you spent a great deal of time getting ,using or getting over the
effects of the drugs?
Mihatag ba ikaw ug dakong panahon, paggamit o nagpabilin dinha sa
epekto sa droga?
10.
Have you given up important activities because of drug use?
Imo bang gi-undang o gi-surrender ang mga importanteng aktibidades o
buluhaton tungod sa imong paggamit sa droga?
11.
Have you kept using drugs even though you knew it could make
you more physically sick or imotionally upset than usual?
Nipabilin ka ba ug paggamit sa droga bisan kabalo ka nga mao kini ang
kinungdan sa mas grabeng mga sakit sa panglawas o dali lang masuko
kesa kaniadto?
NAME: _____________________________________
__________________
DATE:
THE MICHIGAN ALCOHOLISM SCREEN TEST (MAST)

Please circle either YES or NO for each items that applies to you.
1. Do you feel you are a normal drinker? (By normal we mean
you drink less than or as much as most other people.)
2. Have you ever awakened the morning after some drinking
the night before and found that you could not remember a
part of the evening?
3. Does your wife, husband, a parent, or other near relative
ever worry or complain about your drinking?
4. Can you stop drinking without a struggle after one or two
drinks?
5. Do you ever feel guilty about your drinking?
6. Do friends or relatives think you are a normal drinker?
7. Are you able to stop drinking when you want to?
8. Have you ever attended a meeting of Alcoholics
Anonymous (AA)?
9. Have you gotten into physical fights when drinking?
10. Has your drinking ever created problems between you
and your wife, husband, a parent, or other relative?
11. Has your wife, husband (or other family members) ever
gone to anyone for help about your drinking?
12. Have you ever lost friends because of drinking?
13. Have you ever gotten into trouble at work or school
because of drinking?
14. Have you ever lost a job because of drinking?
15. Have you ever neglected your obligations, your family or
your work for two or more days in a row because you were
drinking?
YES
NO
YES
NO
YES
NO
YES
NO
YES
YES
YES
NO
NO
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
O
O
D
L
O
O
D
L
O
O
D
L

City of Iligan
16. Do you drink before noon fairly often?

17. Have you ever been told you have liver trouble? Cirrhosis?
18. After heavy drinking have you ever had Delirium Tremens
(D.T.s) or severe shaking, or heard voices or seen things that
really were not there?
19. Have you ever gone to anyone for help about your
drinking?
20. Have you ever been in a hospital because of drinking?
21. Have you ever been a patient in a psychiatric hospital or
on a psychiatric ward of a general hospital where drinking
was part of the problem that resulted in hospitalization?
22. Have you ever been seen at a psychiatric or mental
health clinic, or gone to any doctor, social worker, or
clergyman for help with an emotional problem, where
drinking was part of the problem?
23. Have you ever been arrested for drunk driving, driving
while intoxicated, or driving under the influence of alcoholic
beverages?
24. Have you ever been arrested, or taken into custody even
for a few hours, because of other drunk behavior?
YES
YES
NO
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Source:
Selzer ML: The Michigan Alcoholism Screening test (MAST): The Quest for a New Diagnostic Instrument.
American Journal of Psychiatry 3:176-181, 1975

City of Iligan
NAME: ______________________________
DATE:_____________
ALCOHOL AND DRUG ADDICTION TEST

To be addicted means that you cannot stop using alcohol or drugs without
help. This was adopted from the Jellinek chart for Addiction.
Instructions: Read each question and think back over your life, If this has
ever happened to you make a check mark in the left column (yes). If this has
never happened to you, make a check mark in the right column (No).
(Basaha ang matag-usa ka pangutana ug lantawa ang imong
kinabuhi. Kung nahitabo na kini kanimo, butang ug tsek ang wala nga
column (yes). Kung wala pa kini mahitabo kanimo, butangi ug tsek ang tuo
nga column (No).
Yes
No
___ ___ 1.
Use to feel better: I use alcohol or drugs to get away from things
that bother me or hard
to face
Mugamit para
maging o.k. ang bation: Nagagamit ko ug
alcohol o droga para makalingkawas sa mga butang na naga-samok
samok sa ako o kanang mga sitwasyon na
lisod atubangon.
____ ______2. Use to solve most problems: I use alcohol or drugs to try to solve
most of my problems
and things that bother me.
Mugamit pa ra ma sulbad ang kadaghanan sa mga problema:
Nagagamit ako ug alcohol o droga para paningkamutna na masulbad
ang kadagahanan sa akong mga problema o mga butang na nagasamok kanako.
_____ _____3. It takes more: It takes more or stronger kind of alcohol or drugs to
get the same feelings
that it used to.
Kinahanglan na daghan: Mas daghan o mas isog pa nga mga kalse na
alcohol o droga ang akong ginagamit para akong bati-on ang pareho
sakong gaibati katong niagi nakong paggamit.
____
_____ 4. Memory Loss: Sometimes after I have been using, I do not
remember what happened.
Pagkawala sa memorya: Usahay, paghuman nako ug gamit, dili nako
makahinomdom kung unsa ang nahitabo.
____ _____ 5. Sneaking: Sometimes I hide from other people how much Im using
or drinking. This might
be because I do not want people to know or because I do not want
to share.
Pagtago-tago: Usahay, itago naku sa uban tao kung unsa kadaghan
akong ginagamit o gina-inom kay dili ko gusto makabalo ang mga tao
o mahitungod kini kay dili ko gusto mag-share.
_____ ______6. Dependence: I rarely do anything for fun unless I use alcohol or
drugs.
Dili kayo ko malingaw kung dili ko mogamit ug alcohol o droga.
_____ ______7. Fast start: I use stronger alchohol or drugs or use a lot quickly at
first to get a good
start.

City of Iligan
____
____
Nagagamit ako ug mas isog na ilimnon o droga o paspas kayo ko

mogamit ug daghan nga droga/ilimnon para makuha ang good start.
______8. Feel guilty: I feel guilty about using alcohol or drugs or about the
thing that I do when I use.
Gibati ug ka-konsiensya: Gibati ko ug ka-konsiyensya batok sa
paggamit ug alcohol/droga o batok sa mga butang na akong ginabuhat
kapag nagagamit ko.
______9. Do not listen: Other people complain or try to talk to me about my
using but I do not listen.
Dili maminaw: Naga-reklamo ang uban tao o ginastoryahan ko sa uban
tao batok sa akong paggamit, apan, dili ko maminaw.
____ ______10. Regular blackout: I do not remember what happened and I get
into trouble when I use
alcohol or drugs.
Dili ko mahinomdom kung unsa ang nahitabo ug mapa-trouble ko
kada-gamit nako ug alcohol or drugs.
____ ______11. Excuses: I use problems in my life as an excuse for using alcohol or
drugs. I feel that I
have to use to deal with these problems.
Ginahimo nakong alibi ang mga problema sakong kinabuhi para
lang makagamit ug droga or alcohol. Akong gibati na kelangan ko
mogamit para atubangon kining akong mga problema.
____ ______12. Using more than others: I use more than most people, so I hang
around people who as
much or more so that I feel that I fit in.
Mugamit ug mas daghan pa kesa sa uban. Mas daghan akong
ginagamit kesa sa uban tao, mao nang muuban ko sa mga taong
pareho nako o mas grabe pa sa ako mugamit para lang akong bati-on
o.k. ko.
____ ______13. Feel bad: I feel bad about how my using hurts other people, but I
dont know what to
do about it.
Lain ang bati-on: Lain akong gibati batok sa kahiubos na ginabatti sa
uban tao tungod sa akong paggamit, pero wala ko kabalo kung unsa
ang akong buhahton.
____ ______14. Show off: I show off or get pushy with other people to ffel bettet
and prove that I am
okay.
Pakitang tao/Pagpanghambog: Nagapang-hambog ko sa uban tao
para maayo ang akong bati-on ug para ma-prove na o.k. ko.
____ ______15. Promises: I show off or get pushy with other people to feel better
and prove that I am
okay. Promise to get my life in order and do better. I mean it, but it
doesnt work out that way.
Pakitang tao/Pagpanghambog: Nagapang-hambog ko sa uban tao
para maayo ang akong bati-on ug para ma-prove na o.k. ko.
____ ______16. Control: I try to control my use, but it doesnt work.
Kontrol: Akong ginapaningkamutan na i-kontrol akong paggamit, pero
dili kini magsilbi.
____ ______17. Give up other things: Ive stopped doing things that I used to do
that didnt involve
using alcohol or drugs.

City of Iligan
I give-up ang uban butang: Akong gi-undangan ug buhat ang mga
butang ug mga aktibidades na akong ginabuhat tong una.
____ _____ 18. Make changes: I can change jobs, move or leave a relationship to
try to make my life
better, but it doesnt make any difference.
Pagbuhat ug kabag-ohan: Nagkambyo ko ug trabaho, ug mibiya sa
akong karelasyon para lang ayoson ang akong kinabuhi pero wala lang
gihapoy nahitabonga kabag-ohan.
____ _____19. Work and money troubles: I have problems on the job, owe money
or cant work at all
because of my using.
Problema sa trabaho ug kwarta: Nagkaproblema ko sa trabaho, nakautang ug kwarta o dili makatrabaho tungod sa akong paggamit.
____ _____20. Avoid friends and family: I avoid old friends and family that do not
use-unless I need
something from them.
Gina-iwassan ang mga amigo ug pamilya: akong gaina-iwasan akong
mga higala ug
kapamilya nga wala nagagamit puwera lang kung naa koy
kinahanglan.
____ _____21. Neglect food: I do not eat healthy foods or eat at regular times,
especially when I am
using.
Pasagdahan ang pagkaon: Wala ko naaga-kaon ug healthy nga
pagkaon o mukaon sa
saktong oras labaw na kung magagamit ko.
____ ____22.Resentment: I feel like other people are out to get me, and I feel
angry a lot.
Pagdumot: Akong gibati na ang uban tao nagabantay sa ako. GIbati
ko ug kasuko.
____ ____23. Withdrawal: I need a drink or a drug in the morning or else I get the
shakes or sweats
because I feel terrible.
Kailangan naku mu-inom o mag droga sa buntag. Kung dili ko ni
buhaton,
magkorog ko ug panington kay terrible akong gibuhat.
____
____24. Cant make decisions: I cant make decisions about even small
things. I just wait until things
happen.
Dili maka-desisyon: Dili ko maka-desisyon maski sa mga gagmay nga
butang. Maghulat lang ko kung nay mahitabo.
____
______25.Health Problems: I am sick, have lost a lot of weight, or feel
physically bad most of the
time.
Problema sa kalusugan. Nakasakit ako, namayat ug taman o nagbaba
ang timbang o kanunay lain ang gibati sa akong kalawasan.
____ ______26. Decrease in amount to get high : It takes less for me to get high
or doesnt matter how much I use because I cant get the effect I
want.
Nagkagamay na maount sa droga para ma-high: Ma high nako
maski gamay lang akong gamiton o usahay, dili na mu-ipekto maski
unsa kadaghan ako gamiton kay tungod dili na nako makuha ang
epekto sa droga na akong gusto.

City of Iligan
____ ______27. Over the line: I do things I said I would never do or things that do
not reflect the way I
was raised.
Pagkalihis: Ginabuhat naku ang mga butang na ingon ko tong una dili
nako buhaton, o ginabuhat nako ang mga butang na kabaliktaran kung
gi-unsa ko pagpadako sa akong ginikanan/kapamilya.
____
______28. Use all the time: I use whenever I can, and dont try to have a
normal life.
Mugamit sa tanang oras: Mugamit ko kung kanus-a nako gusto
mugamit. Wala ko maningkamot nga mabuhi sa normal nga kinabuhi.
____ ______ 29. Find someone worse: I try to use with people who are worse off
than I am so that I feel
better.
Mangita ug kauban na mas grabe: Mugamit ko ug droga/alcohol na
kauban ang mga taong mas grabe pa sa ako para bati-on ug mas o.k.
____
______30. Major damage: Even when Im nor using, I have hard time
thinking, remembering and
doing things that used to be easy.
Dakong kadaotan: Maski wala ko magamit, maglisod ako na makahunahuna, makahinumdom ug buhaton ang mga butang na akong
ginabuhat tong una.
____ ______31. Afraid: I feel like something terrible might happen to me, people
are out to get me, and I have to be on guard at all times.
Mahadlokon: Akong gibati na nay terrible na puwedeng mahitabo sa
ako, ginabantayan ko sa mga tao ug mas dapat mani-id ko sa tanang
panahon.
____ ______32. Give-up: I dont try to change anything, I just want to see what
happens.
Give-up: wala ko nagapaningkamot na mabag-o o bag-ohon ang
maski unsa. Nagahulat lang ko kung unsa ang mahitabo.
____ _____ 33. Using is everything: Getting something to use, using and getting
over using are my
whole life.
Ang paggamit ang kinabuhi: Pagkuha, paggamit ug paglimot sa
paggamit ang akong kinabuhi.
____ _____34. Turn to God: I want God or religion to save me from my life.
Pagdangop sa Ginoo: Gusto nako ang Gino-o o relihiyon na mu-salbar
sa akong kinabuhi.
____ _____35. Im lost: I dont try to pretend my life is normal. I know I am an
addict or an alcoholic. I
believe that things will never change.
Nawala ko: Wala nako ginapaningkamutan na magpaka-aron ingnon na
normal ang akong kinabuhi. Kabalo ko na ako usa ka adik/alkoholik.
Nagtuo akp na dili na magbag-o pa ang mga butang.
____ _____36. Desperation: I am willing to do anything to get better
Pagka-desperado: Buhaton nako ang tanan para lang maayo.
____ _____37.Confinement: I have been in jails and mental wards because of my
using.
Pagka-priso/pagka-kulong: Napriso ko ug nasulod sa mga mental
wards tungod sa akong paggamit.

City of Iligan
Complete the following sentences.

(Kumpletuha ang mga pahayag.)
o
If I do not stop using, I will probably . (Kung dili ko muundang ug

gamit,
mamahimo
akong
..)
_____________________________________________________________
________________________________________________________________________
________________________________________________________________________
If I do not stop using, I might be able to . (Kung dili ko muundang ug
gamit,
basin
makabuhat
ko
ug
..)
______________________________________________________
________________________________________________________________________
________________________________________________________________________
REACTIONS: Complete the sentences below and think about what they
mean for your recovery.
(Kumpletuha ang mga pahayag ug huna-hunnaa kung unsa nag
buot-pasabot ani sa imong pagka-ayo.)
1. How do you feel about the results of the test you just took?
(Unsa ang imong gibati sa mga resulta sa test na imong gikuha?)

City of Iligan
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
2. What do you think about the results of the test you just took?
(Unsa ang imong gihuna-huna sa mga resulta sa test na imong
gikuha?)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3. How do you want to do about the results of the test you just took?
(Unsa ang imong gusto buhaton, karon, na nakabalo naka sa mga
resulta sa test na imong gikuha?)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
SELF REPORTING QUESTIONNAIRE (SRQ)

1. Do you often have headaches?
(Madalas bang sumakit ang iyong ulo?)
2. Is your appetite poor?
(Wala ka bang gana sa iyong pagkain?
3. Do you sleep badly?
(Hindi ka ba nakakatulog ng maigi?)
4. Are you easily frightened?
(Ikaw bay medaling matakot?)
5. Do you feel nervous, tense or worried?)
(Ikaw bay ninenerbyos, nag-aalala at nababalisa?)
6. Do your hands shake?
(Nanginginig ba ang iyong mga kamay?)
7. Is your digestion poor?

City of Iligan
(Ang panunaw mo ba sa pagkain ay hindi maayos?

8. Do you have trouble thinking clearly?
(Ikaw bay nahihirapang mag-isip ng maayos?)
9. Do you feel unhappy?
(Ikaw bay hindi maligaya?
10. Do you cry more than usual?
(Ikaw bay umiiyak ng mas madalas kaysa
pangkaraniwan?)
11. Do you find it difficult to enjoy your daily
activities?
(Nahihirapan ka bang gumawa ng desisyon?)
12. Do you find it difficult to make a decision?
(Nahihirapan ka bang gumawa ng desisyon?)
13. Is your daily work suffering?
(Ang iyong pang- araw-araw na Gawain ba ay
naabala?)
14. Are you unable to play a useful part in life?
(Ikaw ba ay hindi makaganap ng makabuluhang
papel sa buhay?)
15. Have you lost interest in things?
(Nawalan ka ba ng interes sa mga bagay-bagay?)
16. Do you feel that you are a worthless person?
(Sa pakiramdam mo ba ikaw ay walang halaga?)
17. Has the thought of ending your life been in your
mind?
(Ang pagkitil sa iyong buhay ay pumasok na ba sa
iyong kaisipan?)
18. Do you feel tired all the time?
(Nakaramdam ka ba ng di-kaginhawahan sa
sikmura?)
19. Do you have uncomfortable feelings in your
stomach?

City of Iligan
(Nakaramdam ka na ba ng di-kaginhawahan sa
sikmura?)
20. Do you drink alcohol more than usual?
(Madalas ka bang uminom ng alak/tuba kaysa dati?)
21. Do you feel that somebody has been trying to
harm you in some way?
(Sa pakiramdam mo ba ay may nagtangkang
manakit sa iyo?)
22. Have you noticed any interference or anything
unusual with your thinking?
(Ikaw ba ay nakakapuna ng sagabal o anumang dipangkaraniwan sa iyong pag-iisip?)
23. Do you ever hear voices without knowing where
they come from or which other people cannot hear?
(Ikaw bay nakakarinig ng mga tinig na hindi moa
lam kung saan nagmula o kayay hindi naririnig ng
ibang tao?)
24. Have you ever had any fits, convulsions or fall to
the ground, with movements of the arms and legs,
biting of tongue or loss of consciousness?
(Nagkaroon ka na ba ng sumpong, kombulsiyon o
pagkahulog sa lupa na may kasamang panginginig
ng mga ka may at paa, pagkagat ng dila o
pagkawala ng malay?)
25. Have you been living recurrent dreams or
nightmares about the disaster that had happened?
(Nakakaranas ka ba ng paulit-ulit na panaginip
tungkol sa kalamidad/sakuna/krisis/aksidente na
nangyari?)
26. Have you been having flash backs of what had
happened during the disaster at times when you did
not want to think of it or even during times when
there was nothing to remind you of it?
(Nakakaranas ka ba ng madalas na pagbabalik
gunita ng mga nangyayaring sakuna noong may
kalamidad?)

City of Iligan
27. Do you feel bad(e.g. break inn sweat, heart

pounding, difficulty of breathing) when you are in a
situation that reminds you of the disaster?
(Sumasama ba ang pakiramdam mo kagaya ng
pinagpapawisan ng malagkit, kumakabang dibdib,
nahihirapang huminga kung ikaw ay nasa sitwasyong
nakakapag-paalala sa iyo ng
sakuna/aksidente/trahedya?)
28. Do you make it a point to stay away from places
that reminds you of the disaster?
(Sinisiguro mo ba na gumawa ng paraan na lumayo
sa mga lugar na nakapagpapaalala sa iyo ng
sakuna/aksidente/trahedya?
29. Do you experience the feeling of numbness or
having no feeling at all?
(Nakaramdam ka na ba ng pamamanhid o parang
wala kang nararamdaman?)
Summary:
Positive SRQ if there are > 5 Yes Answers for
Questions 1 to 20
Question 21 to 24
Question 25 to 29

City of Iligan
PSYCHOLOGICAL REPORT
1- Identifying Data
Name: _____________________________
_______________
Age/Sex: ___________________________
________________
Home Address: ______________________
_______________
Date of Birth: _______________________
Voluntary
Civil Status: _________________________
Case
Educational Attainment: _______________
Religion: ____________________________
Occupation: _________________________
II-
Date
of
Admission:
Date
of
Interview:
Date
of
Admission:
_______
_______ Court
Reason for Referral
A psychological assessment as a part of a comprehensive case study,

meant to provide the basis for psychosocial therapy or therapeutic
intervention and proper case management.
III- Assessment Procedure
Administered
Michigan Alcoholism Screening Test (MAST)
________________
Readiness for Treatment (RFT)
________________
Alcohol and Drug Addition Test (ADAT)
________________
Drug Screen Inventory (DSI)
________________
Level of Smoking (LS)
________________
Hostility Test (HT)
Ravens Progressive Matrices (RPM)
________________
Bender Gestalt Visual Motor Test (BG VMT)
________________
Draw a Person Test (DAP)
________________
House Tree Person Test (HTP)
IQ and Personality Test (PT)
________________
Date
________________
________________

City of Iligan
Sentence Completion Test (SACHS)

________________
Hand Test (HT)
________________
IV- Substance Used/History

Type of
Substance
Age of First
Use
Why Began
Frequency
Age/Date last
Use
Substance Dependence
Tolerance:
_______ Increased amounts of the substance to achieve the intoxication
or desired effect.
_______ Continued use of the same amount of the substance.
Withdrawal Symptoms:
_______ Tremors
_______ Headache
________ Agitation
_______ Dehydration
________Anxiety
_______ Insomnia
Liability
______ Depressed Mood

________ Sweating
______
Weakness
______ Nausea
______ Hallucination
________
_______ Substance is taken to relieve or avoid withdrawal symptoms

Other _______________
______ Substance is often taken in larger amounts or a longer period of time.
______ Persistent desire or unsuccessful efforts to cut down or control
substance use.
______
Great deal of time spent in activities necessary to obtain the
substance.
______Import social, occupational, or recreational activities give up or
reduced because of substance use.
______Continued substance use despite knowledge of having a persistent or
recurrent physical
or psychological problem
______ With Physiological dependence
______ Without physiological dependence
Substance Abuse

City of Iligan
_______ Failure to fulfill major role obligations at work, school, or home

_______ Persistent social or interpersonal problems.
V- Test Results and Interpretations
(MAST)/ Alcoholism = _____
_______________________________
(RFT)/ R ________
A________
TS ________
RS= _____
DS = _______
ES=
RS= _____
DS = _______
ES=
RS= _____
DS = _______
ES=
(A/DAT)/
Level
of
Addiction
_______________________________
(A/DSI)/ Inventory = _______
______________________________________
_______
Type= ________________
Smoking
Stimulation
= _______
Handling
= _______
Pleasurable Relaxation
= _______
Tension Reduction
= _______
Psychological Addiction
= _______
Habit
= _______
Hostility
Cynicism
Anger
Aggression
= _______
= _______
= _______
Hostility Level
_____________________
_____________________
_____________________
= _______
_____________________
Intellectual Functioning
(Mental Aging)
Results to RPM
Results to BGVMT
RS =
IQ=
PR=
______________
______________
______________
QD=
______________________
________
______________________

City of Iligan
Psychological and Emotional Functioning / (PA)

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________
VI- Assessment
________________________________________________
________________________________________________
________________________________________________
________________________________________________
VII- Remarks/Recommendations
________________________________________________
________________________________________________
________________________________________________
________________________________________________
VIII- Treatment Interventions
_________
_________
_________
_________
Individual Psychotherapy
Group Therapy
Family Therapy
Educational Therapy
Other ________________
Prepared by:
FATHMA SONNAYA M.
MINAGA, RPm
Psychometrician
Noted by:
DR. RAY P. SAGGE, M.D.
Center Psychiatrist

City of Iligan
PROCESS RECORDING
Name of Client: _______________________________
Date
Activity
Recording

City of Iligan
PSYCHOSOCIAL INTERVENTIONS
INTERVIEW GUIDE QUESTIONS
I.
Significant Life Events

Ikuwento mo ang mga nagyari sa buhay mo . yung ,agenda at
hindi magaganda.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
II.
Significant Person
Balikan natin ang mga tao sa buhay mo. Sino-sino ang mga taong
may kinalaman sa buhay mo? Anong masabi mo tungkol sa kanya?
Anong nagging papel niya sa buhay mo? Anong naibigay o naitulong
niya
sa
iyo?
Ano
ang
kailangan
mo
sa
kanya?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
III.
Family Members
Balikan natin ang pamilya mo. Anong masasabi mo tungkol sa
pamilya mo? Balikan natin ang mga tao sa pamilya mo. Sino-sino
ang nasa pamilya mo? Itong si _________
anong ginawa niya? Ano
ang papel nya sa pamilya? Sino ang pinakagusto mo sa pamilya?
Bakit? Sinong pinakaayaw mo? Anong pinaka gustong nangyari o
ginawa ng pamilya mo? Anong pinaka ayaw mong nangyari o
ginagawa ng pamilya mo? Kung may kapangyarihan kang baguhin
ang
pamilya
mo,
ano
ang
babaguhin
mo?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

City of Iligan
IV.
Self Description (ask the child to draw self)

Itong si ____________________ ano naman ang mga katangian niya?
. Yung magaganda tungkol sa kanya? Anonng klasing tao siya?
Saan
ka
magaling?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
V.
Wishes
VI.
Ano ba ang mga gusto mo sanang mangyari sa buhay mo? Ano ba

ang
pangarap
mo?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Experience of Sexual Abuse
Balikan natin yung mga karanasan mo sa sex. Alam mo, minsan, sa
buhay ng isang bata, may mga batang nagkakaroon ng karanansan;
na may taong lumapit sa kanila, hinawakan sila o niyakap, o
hinalikan sila, o sumobok na galawin sila. May nangyari din ba sa
iyong parang ganito? Anong pakiramdam mo noong nangyari yon,
Naaalala o naisip mo pa iyon paminsa-minsan? Gaano kadalas?
Anong nararamdaman mo noong kapag naaaalala mo iyon? Anong
nangyayari sa yo? Anong ginawa? Sa palagay mo, anong epekto
nito sa yo? Anong pinakamalaking epekto nito sa buhay mo?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
VII.
God
Ano ba ang tingin mo sa Diyos, ano ba Siya sa buhay mo?Bakit mo
nasabi iyon? Nagdasal ka ba? Anong sinasabi mo kapag nagdadasal
ka?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
VIII.
Friends

City of Iligan
May mga kaibigan ka ba? Sino? Sinong pinakamatalik mong

kaibigan? Sino naman ang kaaway mo/pinakaayaw mong kasama?
Bakit? Ano ang gingawa nyo kapag magkasama kayo? Anong
pinakagusto
mo
sa
kanya?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
IX.
Lovelife
Nagka girlfriend ka na ba? Ikuwento mo naman. Bakit paano mo
siya naging girlfriend? Gusto mo bang magka girlfriend? Bakit/Bakit
hindi? Anong klaseng tao ang gusto mong maging girlfriend? Gusto
mo bang makapag-asawa? Bakit/ Bakit hindi? Anong klaseng tao
ang gusto maging asawa? Maliban sa nagging karanasan mo na
(Sexual abuse). Nagkaroon ka na ba ng karanasan sa nagging
girlfriend mo, o sa ibang tao? Ano ang tingin mo sa sex ngayon;
pakiramdam mo, ano ang nagging papel mo nito sa buhay mo
ngayon? Ano ba ang pag-ibig o pagmamahal, ano ba ang
pakiramdam
noon?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
X.
Rehabilitation
Anong pinakagusto mong ginawa mo ditto sa center? Bakit? Sinong
pinaka-importante sa iyo ditto sa center? Sinong pinaka-ayaw mo?
Bakit? May pagbabago ba ang buhay mo mula nang dumating ka
dito sa center? Anu-ano yon? Alin ang pinakagusto mong
pagbabaago sa iyo? Bakit? Lumayas ka na ba minsan? Kailan?
Bakit? Bakit ka bumalik? Bakit ka nagtatagal dito? Ano ang
puwedeng mangyari na maiisipan mong umalis/pumuga na hindi ka
na
babalik?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
XI.
Coping
Sa sarili mo naman, anong pinakaayaw mong nangyari sa arawaraw mong buhay? Anong ginagawa mo sa mga ganoong
panahon/pangyayari? Sa mga ginagawa mong ito, alin ang pinaka-

City of Iligan
nakatutulong?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Personal Data Sheet

________________________________________________ Sex _______
Age ______
(Family name)
(First Name)
(M.I.)
Date of Birth: __________ Place of Birth __________________________
Religion:____________
Complete
Home
Address:
_________________________________________________________
______________________________________________________
tel/cell
#:________________
Are you living with parents? Yes _____
No _____ If no, with whom?
______________________
Address:
______________________________________________________________________
Name of Parents
Religion
Educational
Attainment
Occupation
Father: ___________________
___________ ___________________
____________
Mother: __________________
___________ ___________________
____________
Guardian: _________________ ___________ ___________________
____________
# of Brothers _______
# of Sisters _______
Names of Brother and Sisters from the oldest to the youngest:
Include yourself
Age
Age
1. ________________________
_______
6.
________________________
________
2. ________________________
_______ 7. ________________________
________
3. ________________________
_______ 8. ________________________
________
4. ________________________
_______ 9. ________________________
________
5. ________________________
_______ 10. ________________________
________
How do you consider your family? Very rich __ Rich ___Average ___Poor ___
Very Poor ____
______________________________________________________________________________
List the school you have attended and indicate your grade:

City of Iligan
School
Grade
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Were you an honor student? Yes _____ or No ______
Do you have a failing mark? Yes ______ or no _____ if yes, what subjects?
______________________________________________________________________________
Nature of Schooling: Continuous ______ Interrupted _______ if interrupted,
why?
______________________________________________________________________________
Name/s
of
your
best
friends?
______________________________________________________
List the names of organization/s, which you are a member:
______________________________________________________________________________
______________________________________________________________________________
Hobbies:
______________________________________________________________________
Ambition:
_____________________________________________________________________
Substance use History:
Substance Age of
Why Began
Quantity
Date Last Use
1st Use
Spent/Week
Frequency
How Taken
Amount

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What is the purpose of the questionnaire?

What is the purpose of the questionnaire?

What types of questions are asked in the questionnaire?

What types of questions are asked in the questionnaire?

Republic of the Philippines

PERSONAL DRUG USE QUESTIONNAIRE

If I dont change my drug use soon, my

Im not just thinking about changing my

Sometimes I wonder if I am in control of my

I actively do things now to cut down or stop

There are time when I wonder if I use drug

I am working hard to change my drug use

I have made some changes in my drug use;

I really want to make changes in my use of

Republic of the Philippines

DRUG SCREEN INVENTORY

3. Has your drug use resulted in problems with the law?

6. Have you experience withdrawal symptoms or used drugs to make

Republic of the Philippines

THE MICHIGAN ALCOHOLISM SCREEN TEST (MAST)

Republic of the Philippines

16. Do you drink before noon fairly often?

Republic of the Philippines

ALCOHOL AND DRUG ADDICTION TEST

Republic of the Philippines

Nagagamit ako ug mas isog na ilimnon o droga o paspas kayo ko

Republic of the Philippines

Republic of the Philippines

Republic of the Philippines

Complete the following sentences.

If I do not stop using, I will probably . (Kung dili ko muundang ug

Republic of the Philippines

SELF REPORTING QUESTIONNAIRE (SRQ)

Republic of the Philippines

(Ang panunaw mo ba sa pagkain ay hindi maayos?

Republic of the Philippines

Republic of the Philippines

27. Do you feel bad(e.g. break inn sweat, heart

Republic of the Philippines

Reason for Referral

A psychological assessment as a part of a comprehensive case study,

Republic of the Philippines

Sentence Completion Test (SACHS)

IV- Substance Used/History

______ Depressed Mood

_______ Substance is taken to relieve or avoid withdrawal symptoms

Republic of the Philippines

_______ Failure to fulfill major role obligations at work, school, or home

Republic of the Philippines

Psychological and Emotional Functioning / (PA)

Republic of the Philippines

Republic of the Philippines

Significant Life Events

Republic of the Philippines

Self Description (ask the child to draw self)

Ano ba ang mga gusto mo sanang mangyari sa buhay mo? Ano ba

Republic of the Philippines

May mga kaibigan ka ba? Sino? Sinong pinakamatalik mong