Screening and Selection Process

In the following paper I outline the screening process for the members of a group, Adults with a Substance Condition. First are the demographic questions and second are the screening questions. I then discuss how I will use the screening questions as selection and deselection criteria. Finally, I discuss the final step of the screening process, the one-on-one interview.

Demographic Questions

  1. Name:__________________________________________________________________
  2. Address:________________________________________________________________
  3. Cell Phone:______________________________________________________________
  4. Home Phone:_____________________________________________________________
  5. What is your age?_____
  6. What is your sex?_____
  7. How would you describe yourself? (Please check the option that best describes you)
  • American Indian
  • Pacific Islander
  • Asian
  • African American
  • Hispanic
  • Non-Hispanic White
  1. Are you:
  • Married
  • Divorced
  • Separated
  • Never been married
  • Member of an unmarried couple
  1. Are you currently:
  • Employed
  • Self-employed
  • Out of work for more than 1 year
  • Out of work for less than 1 year
  • A homemaker
  • A student
  • Retired
  • Unable to work
  1. What is the highest grade or year of school you completed?
  • Never completed high school
  • High school graduate
  • Some college
  • Community college graduate (AA degree)
  • College graduate (B.S. or B.A. degree)
  • Graduate School (Advanced degree)

Screening Questions            

  1. Are you a substance abuse addict?____________________________________________

If so, what is your drug of choice?____________________________________________

Secondary drug of choice?__________________________________________________

  1. Do you want to be clean and sober?___________________________________________
  2. Do you have any mental health conditions?_____________________________________

If so, what are they?_______________________________________________________

  1. Do you currently take any prescribed medications?_______________________________

If so, what are they?_______________________________________________________

  1. Are you suicidal?_________________________________________________________
  2. Are you homicidal?________________________________________________________
  3. Do you experience episodes of rage?__________________________________________
  4. Have you experienced trauma recently?________________________________________

If so, explain:____________________________________________________________


  1. Are you in the midst of an extreme crisis?______________________________________

If so, explain_____________________________________________________________

  1. Do you experience episodes of paranoia?_______________________________________
  2. Have you been to treatment for your substance condition?_________________________

If so, which treatment center?________________________________________________

How long were you in treatment?_____________________________________________

What was your discharge date?_______________________________________________

  1. Are you in a sober living home or are you planning on moving into a sober living home?__________________________________________________________________

If so, what is the name of the sober living home?________________________________

  1. Are you willing to commit to at least sixteen weeks with this counseling group?________
  2. Are you willing to complete homework assignments and share with the group? (i.e. relapse prevention plan)____________________________________________________
  3. Are you willing to confront difficult issues in your life and are you willing to learn techniques to handle the issues more effectively?________________________________
  4. Are you willing to support other members of the group? (i.e. listening, caring, opening up)_____________________________________________________________________