Name_______________________________________________ Date: __________________________
Circle the number that applies to you today: 0 = Not at all, 1 = Just a little, 2 = Occasionally, 3 = Some of the time; a fair amount of the time; 4 = Frequently or most of the time.
| 0 | 1 | 2 | 3 | 4 | A. I am able to think/talk
about the abuse or the sexual abuse when it is appropriate.
| 0 | 1 | 2 | 3 | 4 | B. I am able to think/talk
about things other than the abuse or sexual abuse.
| 0 | 1 | 2 | 3 | 4 | C. I sleep adequately; I don't
feel unusually sleepy in the daytime.
| 0 | 1 | 2 | 3 | 4 | D. I feel part of a supportive
family.
| 0 | 1 | 2 | 3 | 4 | E. I stand up for my self (I am
reasonably assertive).
| 0 | 1 | 2 | 3 | 4 | F. I maintain physical
appearance (weight, hair, nails etc.)
| 0 | 1 | 2 | 3 | 4 | G. I go to work; I am on time,
I am reasonably productive.
| 0 | 1 | 2 | 3 | 4 | H. I am satisfied with my
work.
| 0 | 1 | 2 | 3 | 4 | I. I engage in social
activities outside the home.
| 0 | 1 | 2 | 3 | 4 | J. I have a healthy
appetite.
| 0 | 1 | 2 | 3 | 4 | K. I care for child, loved
ones, pets. (I can take care of others.)
| 0 | 1 | 2 | 3 | 4 | L. I adapt to new
situations.
| 0 | 1 | 2 | 3 | 4 | M. I initiate contact with
friends, loved ones.
| 0 | 1 | 2 | 3 | 4 | N. I show a sense of
humor.
| 0 | 1 | 2 | 3 | 4 | O. I am interested in future
goals.
| 0 | 1 | 2 | 3 | 4 | P. I pursue leisure activities.
| 0 | 1 | 2 | 3 | 4 | Q. I exercise regularly.
| 0 | 1 | 2 | 3 | 4 | R. I take sensible protective
measures inside and outside house.
| 0 | 1 | 2 | 3 | 4 | S. I choose supportive
relationships over non-supportive ones.
| 0 | 1 | 2 | 3 | 4 | T. I am able to relax without
drugs or alcohol.
| 0 | 1 | 2 | 3 | 4 | U. I seem to tolerate
constructive criticism well.
| 0 | 1 | 2 | 3 | 4 | V. I seem to accept praise
well. I thank the person giving the praise.
| 0 | 1 | 2 | 3 | 4 | W. I enjoy a healthy sexual
relationship. I can give and accept intimacy.
| 0 | 1 | 2 | 3 | 4 | X. I have long term
friendships.
| 0 | 1 | 2 | 3 | 4 | Y. I am satisfied with
relationship with spouse or partner.
| 0 | 1 | 2 | 3 | 4 | Z. My partner or spouse would
say that relationship is healthy and satisfying.
OTHER SIGNS OF RECOVERY (Please list any which are important to
you):
| 0 | 1 | 2 | 3 | 4 | AA. My dreams are usually
tolerable and not very upsetting.
| 0 | 1 | 2 | 3 | 4 | BB. My attention span is
fairly good and I can concentrate well.
| 0 | 1 | 2 | 3 | 4 | CC. I experience a wide range
of emotions, both pleasant and unpleasant.
| 0 | 1 | 2 | 3 | 4 | DD. People would say I am more
calm than jumpy