ADDICTION SURRENDER WORKSHEET

Type of Addiction:

• What type of addiction are you struggling with?

a) Alcohol

b) Drugs

c) Gambling

d) Other (Specify) ____________.

History of Use:

• How long have you been taking the substance or using the addictive substance or practicing the addictive act?

             _______ (Years/Months)

• How frequently do you use or participate in any addictive behavior?

a) Daily  

b) Weekly        

c) Monthly

d) Occasionally

• How much quantity do you take per time?

Negative Effects:

• Explain the ways in which addiction has had a negative impact on your life:

Triggers:

• Complete the sentence:

When I feel ___________, I turn to my addiction.

Exploration of Causes and Triggers:

• Complete the sentence:

There could be _______________ as the source of my addiction.

• True or False: I do not think genetic factors influence my addiction in a major way.

a) True

b) False

Development of Coping Strategies:

• Complete the sentence:

Another action plan I can employ to fight temptation is ___________________.

Support and Resources:

• True or False: Sometimes relying on the family and friends may be very useful in the process of my recovery.

a) True

b) False

• Complete the sentence:

One of the resources that I can use in order to seek assistance is ______________.

Action Plan:

• True or False: First and foremost, the goals stated in my action plan must be realistic and attainable.

a) True

b) False

• Complete the sentence:

In the next few months, my goal is ____________________________.

References:

1. Marlatt, G. A., & Donovan, D. M. (2005). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York, NY: The Guilford Press.
2. McLellan, A. T., Lewis, D. C., O'Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA, 284(13), 1689-1695.

You can download more Mental Health worksheets here.

Please note: There may be a more up-to-date and editable version of this worksheet available here which may be more suitable to present to clients if you are a therapist or to use in a classroom as a teacher or guidance counsellor.