Transitions Therapy

SUPPORTING THE CHANGES IN YOUR LIFE

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Anxiety Inventory

Anxiety Inventory Disclosure: This questionnaire is to be used as a tool to give you and your therapist some ideas about what is going on for you right now in the area of addiction/chemical dependency. It is not a diagnostic tool and is not intended to diagnosis you in any way.

Please answer all questions as best as you can.

Send the completed form to: *

Name

Email *

1. I have visible signs of nervousness such as sweaty palms, shaky hands, nauseous:

Never
Sometimes
Often
Frequently
Most of the time

2. I have "butterflies" in my stomach when I have to do something new:

Never
Sometimes
Often
Frequently
Most of the time

3. I have a hard time stopping myself from doing certain things repeatedly, such as: counting, checking on things, washing your hands, re-arranging objects, repeating things until it feels "right," collecting useless objects:

Never
Sometimes
Often
Frequently
Most of the time

4. I have been through or been exposed to a traumatic event:

Never
Sometimes
Often
Frequently
Most of the time

5. I panic before driving my car or preparing for work/school:

Never
Sometimes
Often
Frequently
Most of the time

6. It feels like mind goes blank:

Never
Sometimes
Often
Frequently
Most of the time

7. I have repetitive thoughts that interfere with my work and/or social life:

Never
Sometimes
Often
Frequently
Most of the time

9. I make mistakes on easy questions or put answers in the wrong places:

Never
Sometimes
Often
Frequently
Most of the time

10. I have difficulty making choices:

Never
Sometimes
Often
Frequently
Most of the time

11. I need someone to go with me when I have to go someplace new:

Never
Sometimes
Often
Frequently
Most of the time

12. I feel overwhelmed by sounds, light, and movements:

Never
Sometimes
Often
Frequently
Most of the time

14. I worry about my health constantly:

Never
Sometimes
Often
Frequently
Most of the time

15. It’s very difficult for me to relax and let go:

Never
Sometimes
Often
Frequently
Most of the time

16. I have recurrent and persistent ideas, thoughts, impulses, or images that are intrusive, unwanted, senseless, or repugnant:

Never
Sometimes
Often
Frequently
Most of the time

17. I have trouble keeping my mind on one thing:

Never
Sometimes
Often
Frequently
Most of the time

18. I feel irritable, and angry frequently:

Never
Sometimes
Often
Frequently
Most of the time

19. I have headache for no apparent reason:

Never
Sometimes
Often
Frequently
Most of the time

20. I have an intense fear that I will do something or say something embarrassing:

Never
Sometimes
Often
Frequently
Most of the time

21. I am afraid to make a mistake in front of other:

Never
Sometimes
Often
Frequently
Most of the time

22. I often feel that others are watching and judging me:

Never
Sometimes
Often
Frequently
Most of the time

23. There are things I don’t do and people I don’t speak to because of my fear of embarrassment:

Never
Sometimes
Often
Frequently
Most of the time

Any other information our counselor needs to know?

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