ACDI-CV II Instructions You are completing this inventory to give the staff information that will help them evaluate your situation and needs. Your honesty in completing this inventory is important. The statements are numbered and each one must be answered. Match the number of the statement with the number on your answer sheet. Read each statement carefully and choose the answer that is accurate for you. Do not skip any answers. In this inventory, alcohol refers to beer, wine and other liquor. Drugs refer to marijuana (pot), cocaine (coke), crack, barbiturates, amphetamines and heroin. If you have any questions, ask the supervisor for help. When you understand these instructions you may begin. Do not make any marks on this booklet. Section 1 The following questions must be answered True or False. If a statement is True put an X under T for True on your answer sheet. If a statement is False put an X under F for False. All statements must be answered. 1. I have been embarrassed at school by mistakes I have made. 2. I often feel upset and unhappy with my life. 3. I have used alcohol (beer, wine or liquor) more than I should. 4. I believe I am more unhappy than others my age. 5. I have used drugs too much and too often. 6. I have a short temper and get very angry quickly. 7. Sometimes I worry that people may think badly of me. 8. I am dissatisfied and unhappy with my life. 9. My family is worried about my drinking. 10. My relationship with my parents has gotten worse this last year. 11. I have been told I have a drug problem. 12. I worry about keeping my temper under control. 13. At times I get angry and upset at myself. 14. I have a lot of problems and concerns. 15. I am concerned about my drinking. 16. I am turned off in school and don t even try anymore. 17. Many of my close friends use drugs. 18. I often have problems getting along with others. 19. It bothers me when I am overlooked or ignored by people I know. 20. I frequently feel discouraged and friendless. 21. Drinking is becoming a problem for me. 22. My parents say they do not trust me anymore. 23. There are times when I worry about my use of drugs. 24. Two or more of the following apply to me (answer true or false on your answer sheet): a. Rowdy or disruptive b. Rough or callous c. Forceful or violent d. Outbursts or explode e. Tough or argumentative 25. There have been times when I have known my parents did not want me to do something, but I did it anyway. 26. I feel alone and unhappy. 27. I have lied to people about my drinking -- either saying I drink less than I do, or hiding the fact that I drink at all. 28. I am often unfriendly and uncooperative. 29. I use and sometimes abuse drugs. 30. There are times I get so angry I cannot control myself. 31. There are times when I am really down, depressed and unhappy.
32. Two or more of the following apply to me (answer true or false on your answer sheet): a. Uneasy, anxious or troubled b. Mental or physical suffering c. Sorrow, misery or grief d. Pain, suffering or distress e. Confused, disturbed or distracted 33. This last year drinking has been a problem for me. 34. I have a lot of problems at school like being late, ditching and not turning in my homework. 35. My family is worried that I may have a drug problem. 36. I am more destructive and dangerous than others my age. 37. I have been jealous or resentful of others. 38. I know it s strange, but I often feel shaky, jittery or trembling inside. 39. My drinking is more than just a little or minor problem. 40. I seem to have more trouble and problems than most people my age. 41. A close family member has said that I should get help for my drug problem. 42. If someone hurts or insults me, I usually try to get even. 43. There have been times at school when I did not pay proper attention to what I was doing. 44. This past year I have been very unhappy and depressed. 45. My drinking has caused family and social problems for me. 46. Two or more of the following apply to me (answer true or false on your answer sheet): a. Dropped out or failed in school b. Ran away from home at least twice c. Lot of family arguments or fights d. Negative and uncooperative attitude e. Trouble with the juvenile authorities 47. I have smoked marijuana (pot) or used drugs before school or at lunch time. 48. I have violent temper tantrums and often break or smash things. 49. There are times at home when I get really frustrated and angry. 50. I often feel like I want to give up on everything. 51. I need help with my drinking problem. 52. My parents do not like my friends or the people I hang out with. 53. I have attended Narcotics Anonymous (NA) or Cocaine Anonymous (CA) for help with my drug problem. 54. When angered I am dangerous. 55. I have done things I know my parents did not want me to do. 56. I feel like no one cares about me anymore. 57. I have a drinking problem. 58. I do not know why, but I keep getting into trouble. 59. Sometimes when I use drugs my personality changes and I seem like a different person. 60. I am a member of a gang. 61. I have been offended and hurt by what someone said about me. 62. I know I am unhappy and need help. 63. I have had two or more memory losses (blackouts) after drinking. 64. People say I am very touchy or overly sensitive. 65. I am a violent person. 66. I have done some things that were wrong and I was not caught. 67. I need someone I can talk to about my problems and the things that are bothering me. 68. There are times when I get very discouraged. 69. I often think about death, dying and suicide. 70. I am unhappy at home and only stay there because I have to. 71. My use of drugs has threatened my happiness and success in life. 72. I have said and done things when I was angry or mad that I regret. 73. I often think about revenge and how I can get even.
74. There are times when I worry about myself, my friends and my popularity. 75. I need help. 76. I have lied to my parents. 77. This last year I have runaway from home or moved out on my own. 78. I have a drug abuse or drug-related problem. 79. People tell me I have a bad attitude and quick temper. 80. I am ashamed of some of the things I have said or done. 81. I would like to talk with a counselor about my problems and concerns. 82. Drinking has gotten in the way of my happiness and success in life. 83. Sometimes I daydream about being important, rich or popular. 84. I have very few problems at home or at school. 85. I have been in counseling or treatment for my drug use. 86. I have a lot of anger, resentment and hostility toward others. 87. There are times when I worry about what people think or say about me. 88. I am discouraged and often feel left out or alone. 89. I have attended Alcoholics Anonymous (AA) meetings for help with my drinking. 90. People tell me I am negative, resistant and uncooperative. 91. My favorite drug is pot (marijuana) or coke (cocaine). 92. I can be dangerous when insulted or embarrassed. 93. I usually get upset when others criticize me. 94. Lately I have been feeling uptight and worried, like something bad is going to happen but I don t know what it is. 95. I have been told I am an alcoholic. 96. I have been in alcohol treatment for my drinking problem. 97. I need someone I can talk to about my problems and the things that are bothering me. 98. I have lied to people about my use of drugs -- either saying I use less than I do, or hiding the fact that I use drugs at all. 99. Sometimes I really worry about my responsibilities and happiness. 100. I am a nonviolent person. Section 2 The following statements are to be rated to describe yourself. Put an X under the number (1, 2, 3 or 4) on your answer sheet that describes you best. Answer each statement as it applies to you now. 1. Rare or Never 3. Often 2. Sometimes 4. Very Often or Always 101. Exercise / Physical Activity 102. Self Control / Composed 103. Positive Attitude / Outlook 104. Dissatisfied with Life 105. Good Sense of Humor / Laugh 106. Anxious / Worried / Fearful 107. Depressed / Discouraged 108. Satisfied with Self / Like Self 109. Angry / Hostile / Irritable 110. Enthusiastic / Involved with Life 111. Tension / Stress 112. Directly Deal with Problems 113. Emotionally Upset / Crying 114. School Problems / Concerns 115. Inadequate / Worthless / Hopeless 116. Able to Handle Life s Problems 117. Nervous / Unable to Relax 118. Patient / Tolerant / Understanding 119. School Satisfaction 120. Loss of Control / Explode / Blow-up
Section 2, continued 121. Trust My Own Judgment 122. Difficulty with Others / Conflict 123. Family Problems / Concerns 124. Tired / Trouble Sleeping 125. Satisfied / Contented 126. Bored / Restless 127. Lonely / Unhappy 128. Admit My Errors / Mistakes 129. Accepting / Quiet / Peaceful 130. Family Arguments / Fights Section 3 The following series of statements should be answered to describe yourself. Select the number (1, 2, 3 or 4) of the answer that is accurate for you and place an X under that number on your answer sheet. Answer the questions as they apply to you now. 131. How would you describe your drinking? 1. Serious problem 2. Moderate problem 3. Mild problem 4. No problem 132. How would you describe your desire for alcohol treatment or help? 1. I want help 2. I am undecided 3. I can handle it myself 4. There is no need 133. Recovery means having an alcohol or drug problem, but not drinking or using drugs anymore. I am a recovering: 1. Alcoholic 2. Drug abuser 3. Both 1 and 2 4. None of the above 134. How long has it been since you were a gang member? 1. Less than two years 2. Three years or more 3. I am a gang member 4. I have never been a gang member 135. Select the statement that best describes your family or home. 1. Family problems 2. Problems with family members 3. Both 1 and 2 4. None of the above 136. How would you describe your use of drugs? 1. Serious problem 2. Moderate problem 3. Mild problem 4. No problem 137. How would you describe your desire for drug treatment or help? 1. I want help 2. I am undecided 3. I can handle it myself 4. There is no need 138. Rate your present level of distress (anxiety and depression) on a scale from 1 to 10. One represents no distress and ten represents severe distress. 1. No distress (rating of 1 or 2) 2. Little distress (rating of 3 to 5) 3. Moderate distress (rating of 6 to 8) 4. Severe distress (rating of 9 or 10) 139. Select the answer that applies to you. During the last six months, I have been: 1. Dangerous to myself (suicidal) 2. Dangerous to others (homicidal) 3. Both 1 and 2 (suicidal and homicidal) 4. None of the above 140. How would you describe your desire for counseling or help? 1. I want help 2. I am undecided 3. I can handle it myself 4. There is no need Please return this booklet and your answer sheet to the supervisor. v4.01 Thank you for your cooperation.
ACDI-Corrections Version II Answer Sheet First Name: Last Name: Middle Initial: Last Four Digits of SSN: Ethnicity (race): Age: Sex: Education (highest grade completed): Date of Birth: 1. Your age at your first arrest: 2. Number of times on probation: 3. Number of probation revocations: 4. Total number of times arrested: Today s Date: Accurately complete the following: 5. Number of times in juvenile detention: 6. Number of juvenile court hearings: 7. Number of alcohol-related arrests: 8. Number of drug-related arrests: Section 1 The following questions must be answered True or False. If a statement is True put an X under T for True on your answer sheet. If a statement is False put an X under F for False. All statements must be answered. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. Section 2 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100.
Rate how you feel about yourself. Put an X under the number (1, 2, 3 or 4) that applies to you now. Use the following rating scale. 1. Rare or Never 3. Often 2. Sometimes 4. Very Often or Always 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. Section 3 The following series of statements should be answered to describe yourself. Select the number (1, 2, 3 or 4) of the answer that is accurate for you and place an X under that number on your answer sheet. Answer the questions as they apply to you now. 131. 132. 133. 134. 135. 136. 137. 138. 139. 140. v4.01