Substance Use Questionnaire

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Content in this survey may be intellectually or emotionally triggering, please do not feel the need to participate if there are feelings of discomfort when discussing substance use disorder. Please refer to SAMHSA's National Helpline if you/someone you know is struggling with substance use disorder. Its free, confidential, 24/7, 365-day-a-year treatment referral and information service (in English and Spanish) for individuals and families facing mental and/or substance use disorders.

1-800-662-HELP (4357)

Hello all! I am an Occupational Therapy Doctorate Student. Next spring, I will be completing my capstone project and I have a Google Form I would like participants to answer to determine the need for a program I would like to begin. I am interested in creating an occupational therapy-based program for clients recovering from substance use disorder. If you have a family member, son, daughter, or are an individual yourself with substance use disorder, I would greatly appreciate your responses. Thanks so much!

*This is an anonymous survey*

What aspects of your life do you find more challenging and/or needs improvement due to your experiences with substance use disorder?

Social

Leisure

Education

Work

Sleep/Rest

Other:

Do you have any other diagnosis(es) along with substance use disorder?

Yes

Unsure

Prefer Not to Answer

Clear selection

If answered "Yes", what is your diagnosis(es)?

Do you feel you were able to easily access resources for treatment?

Yes

Unsure

Prefer Not to Answer

Other:

Clear selection

Do you feel you were provided enough resources when transitioning out of a recovery clinic?

Yes

Unsure

Prefer Not to Answer

Clear selection

Do you participate in any of the listed aftercare services?

12-step Programs

Indvidual Therapy

Group Counseling

Unsure

Prefer not to Answer

Other:

If applicable, where did you receive recovery services?

Inpatient

Outpatient

Behavioral Therapy

Unsure

Prefer Not to Answer

Other:

What interventions worked best for you while in a recovery clinic?

Did you receive Occupational Therapy services during your treatment?

Yes

Unsure

Prefer Not to Answer

Clear selection

If answered "Yes", did you find the treatment helpful?

Yes

Unsure

Prefer Not to Answer

Clear selection

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