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    Substance Use Questionnaire BCBOBS

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    harpreetharry360

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    © All Rights Reserved
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    Substance Use Questionnaire BCBOBS

    Uploaded by

    harpreetharry360
    5 views2 pages

    Original Title

    Substance-Use-Questionnaire-BCBOBS

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    Copyright:

    © All Rights Reserved
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    5 views2 pages

    Substance Use Questionnaire BCBOBS

    Uploaded by

    harpreetharry360

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Substance Use Questionnaire

    Student Name: ____________________________________________ Course # _________________

    During the enrollment process, you indicated that you have a history of substance abuse, dependency or treatment.
    We would appreciate your response to the following questions.

    1. Have you been in treatment or counseling for substance related issues? Yes No

    2. Please check all that apply


    Residential treatment? From to Completed? Yes No
    Outpatient treatment? From to Completed? Yes No
    Support group? From to Completed? Yes No
    Other ____________ From to Completed? Yes No

    3. What substance(s) were your in treatment or counseling for?

    4. Do you abuse/use more than one substance at a time?

    5. Where would place your substance use on the following scale:


    Exploratory Recreational Abusive Dependent
    |_______________________|______________________|____________________|

    6. What events caused you to seek treatment?

    7. What are your triggers for using drugs or alcohol?

    8. Have you had "blackouts" or "flashbacks" as a result of substance use? Yes No

    9. Can you get through a week without using substances? Yes No Unknown

    10. Have you had withdrawal symptoms (felt sick) when you stopped taking substances? Yes No

    11. Are you always able to stop using substances when you want to? Yes No Most of the time

    Outward Bound Substance Use Questionnaire 2011 - Page 1 of 2


    12. Has substance abuse created problems between you and your friends or family? Yes No

    13. Have you been in trouble at work or school because of your use of substances? Yes No

    14. What goals or objectives do you hope to achieve on your Outward Bound ® Course? What are your
    expectations?

    15. Are you using Outward Bound as a way to stop using drugs or alcohol? Yes No

    16. Are you willing to stop using any drugs or alcohol at least 90 days before your course? Yes No

    17. Do you understand that possessing, obtaining or using any drugs or alcohol that are not prescribed or
    disclosed on your medical form will result in immediate dismissal from your course with no refund of
    tuition? Yes No

    Who filled out this questionnaire? The applicant Parent/Guardian Other:

    Participant Signature Date

    Parent/Guardian Signature (If 21 years old or under) Date

    Outward Bound Substance Use Questionnaire 2011 - Page 2 of 2

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