Optional Health Assessment Modules Form Page 16
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27OPTIONAL MODULE 8:
UR Number:
ASSESSMENT OF
Surname:
Given name:
RECOVERY CAPITAL
Date of birth:
(Please fill in if no label available)
PURPOSE OF MODULE
INTRODUCTION FOR CLIENT
To identify internal and external resources and strengths that individuals
“Now I’m going to ask you a series of statements about strengths you
can draw upon to help them meet their recovery and treatment goals.
may possess to help you meet your goals.”
INSTRUCTIONS
WHO CAN ADMINISTER THIS MODULE?
1. Tick boxes that the client agrees with.
This module can either be self-completed by the client or administered by
2. Tally responses and provide feedback on strengths.
the clinician.
3. Use areas of strengths as prompts for the strengths mapping exercise
in the next module as desired.
1. SUBSTANCE USE & SOBRIETY
YES
I am currently completely sober
I feel I am in control of my substance use
I have had no ‘near things’ about relapsing
I have had no recent periods of substance intoxication
There are more important things to me in life than using substances
TOTAL
/5
2. GLOBAL HEALTH (PSYCHOLOGICAL)
YES
I am able to concentrate when I need to
I am coping with the stresses in my life
I am happy with my appearance
In general I am happy with my life
What happens to me in the future mostly depends on me
TOTAL
/5
3. GLOBAL HEALTH (PHYSICAL
YES
I cope well with everyday tasks
I feel physically well enough to work
I have enough energy to complete the tasks I set myself
I have no problems getting around
I sleep well most nights
TOTAL
/5
FOR STAFF ONLY
Clinician name:
Position:
Signature:
Date:
15
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