YEP! Self-Assessment (Albuquerque) – Serna Solutions LLC

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YEP! Self-Assessment (Albuquerque)

Serna-YEP Questionaire (Albuquerque)

Your information is secure and CONFIDENTIAL. It will not be shared with anyone without your permission.

The following best describes my viewpoint:

I make my own choices as to how I spend my time

Most of what I do is based on what other people tell me I must do

I have conflict in my family:

Never

Daily

Multiple times a week

Constantly

The following best describes the way I feel about school:

I don’t like school & I fail to see the point

I skip school often & am considering dropping out

I stopped going to school

I show up & I do the best I can

I work hard & I do well in school

Doing well in school is important to me

The following best describes my current feelings about my substance use: (check one)

I don’t think my substance use is a problem and I don’t know why other people make a big deal of it

I think about the consequences of my substance use and sometimes I wonder what it might be like to quit, but I’m not sure I want to

I’m ready to make a change, I realize that I need to do something about my substance use

I know that I have the power to change and I am committed to and actively working on changing my behavior

I am proud of the progress I’ve made and I am able to resist the temptation to revert back to my old behaviors

In the past 30 days I have used the following substances:

Alcohol

THC (any form)

Heroin

Fentanyl

Xanax, Valium, Librium, Ativan

Adderall

Cocaine

Crack

Methamphetamine

Ecstasy

Acid

Psilocybin

Ketamine

Kratom

Oxycodone (OxyContin, Percocet), Hydrocodone (Vicodin)

I use one or more substances:

Once a day

Multiple times a day

Once a week

Multiple times a week

I most often use one or more substances:

In the morning upon waking

In the afternoon

In the evening or at night

I use substances to: (check all that apply)

Numb unpleasant feelings

Cope with stress/pressure

Reduce anxiety

Reduce depression

Have more self-confidence

I do not use substances, but I am finding my life to be very difficult to manage in the following areas:

Family relationships

Peer relationships

School

Self-image

Anxiety/Depression

Name *

Name

First

First

Last

Last

Email *

Phone

I am interested in (check all that apply): *

In-Person Group Meetings (Santa Fe)

In-Person Group Meetings (Albuquerque)

Online Group Meetings

Any

None at this time, but please contact me

If you are human, leave this field blank.

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CONTACT US ALBUQUERQUE

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Email info@sernasolutionsllc.com

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Santa Fe, NM 87507

SF (505) 207-8929

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6000 Uptown Blvd. Ste 140
Albuquerque, NM 87110

ABQ (505) 305-4949

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4101 Barbara Loop
Rio Rancho, NM 87124

Rio Rancho (505) 527-9494

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