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Questionnaire for Addiction

Your information will be kept confidential and used only for the purpose of providing hypnosis

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How often do you use?
What is the strongest feeling that comes up when you think about your substance use?
How much does substance use affect your daily life?
What areas are most affected? (Check all that apply)
When do you most often use? (Check all that apply)
Do you find yourself using automatically without thinking?
How soon after waking do you use?
What happens when you try to cut back? (Check all that apply)
How ready are you stop using?
What made it difficult to stay quit?
Do you have support in your life for quitting?
Yes
No
Not sure
Are you currently under medical care or taking prescribed medications?
Yes
No

DISCLAIMER: I, Nicole Marie, am not a medical doctor, psychiatrist, or psychologist, nor do I carry any sort of license to practice medicine.  I do not diagnose, prescribe, or provide medical treatment. All healing is self healing and voluntary. I recommend that clients continue to see their regular medical doctors and follow their advice. The work that I do does not take the place of conventional medicine or treatment for any medical or psychological condition. If you are in need of medical treatment, diagnosis, or psychological care, you should seek the proper licensed physician or healthcare professional.  My spiritual work is not for everyone, nor does it have the same results or outcome for everyone. I do not make any guarantees, warranties, or promises in regards to the results or outcome of my spiritual work.

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