NCI’S WARRIOR TOUGH-MINDEDNESS SCALE

What are your clans?

Fluent in Navajo? (INTAKE) Yes, No, Other Native Language

Spiritual/religious preference: Traditional, NAC, Church, None

Are you a Veteran? (INTAKE)Yes, No

After you requested services, how many days did you wait before you had your first face-to-face meeting with a service provider (INTAKE):

What is your current mailing address and telephone number?

Physical address (Map on back if needed):

Could you give me the physical and mailing addresses of an emergency contact?

1- Single, 2- Parent(s), 3- Other family members, 4- Spouse, Girlfriend/Boyfriend, 5- Children, 6- Friends, 7- Homeless

Do you have a spouse or girlfriend/boyfriend? Yes, No

Are all of your school-aged children living with you Yes, No

If not, is this due to a drinking-related problem? Yes, No

Does anyone in your household have a drinking problem? Yes, No

Are you currently working?

1- Full-time, 2- Part-time, 3- Self-employed, 0- Not working. If not, why not?

What was your general work history over the past six months:

Do you have your own transportation Yes, No

Do you have a valid driver’s license Yes, No

Are you having any health problems? Yes, No

If yes, what?

Is this related to your drinking? Yes, No, NA

If a younger female, are you pregnant? Yes, No, NA

Have you been to the Emergency Room over the past 6 months for a substance-abuse related problem? Yes, No

Why did you decide to attend Eagle Plume? (INTAKE, 6 MONTHS)Self-referred,

If referred by others, whom:

If court-ordered, for what offense:

PSYCHOLOGICAL FUNCTIONING

1. Times I have felt hopeless: ever, rarely, sometimes, often, always

2. Times I have felt depressed: never, rarely, sometimes, often, always

3. Times I felt happy: never, rarely, sometimes, often, always

4. Times I have felt lonely: never, rarely, sometimes, often, always

5. Times I felt frustrated: never, rarely, sometimes,

6. Times I have felt satisfied: never, rarely, sometimes, often,#9;always

7. Times I have felt angry: never, rarely, sometimes, often, always,

8. Times I worry: never, rarely, sometimes, often, always

9. Times I have felt like joking: never, rarely, sometimes, often, always

10a. Times others unfairly criticized me: never rarely, sometimes, often, always

13. Times I have been glad to be alive: never, rarely, sometimes, often, always,

14. Times I have felt comfortable with myself: never, rarely, sometimes, often, always

15. Times I have felt bad about myself: never, rarely, sometimes, often, always

16. Times I think others like me: never, rarely, sometimes, often, always

17. Times I think my family wants me around: never, rarely, sometimes, often, always

18. Times I value myself or think I’m important: never, rarely, sometimes, often, always

19. Times I felt others were embarrassed because of me: never, rarely, sometimes, often, always

21. Times I do a good job (chores, family): never, rarely, sometimes, often, always

22. Times I’m proud to be a Native American: never, rarely, sometimes, often, always

PURPOSE AND MEANING

23. Times my life is important to me: never, rarely, sometimes, often, always

24. Times my life has meaning: never, rarely, sometimes, often, always

25. Times I think my family needs me: never, rarely, sometimes, often, always

26. Times I actually do what I set out to do: never, rarely, sometimes, often, always

27. Times I am satisfied with life: never, rarely, sometimes, often, always

28. Times I have things I need to accomplish: never, rarely, sometimes, often, always

SPIRITUAL VALUES

29. Times I respect Nature and the Holy Ones: never, rarely, sometimes, often, always

30. Times I feel spiritually strong: never, rarely, sometimes often, always

31. Times I pray for others: never, rarely, sometimes, often always

32. Times I feel blessed and protected: never, rarely, sometimes, often, always

33. Number of times when I pray or do something spiritually important to me: never, rarely, sometimes, often, always

34. My knowledge of personal spiritual

practices is: none, slight, medium, strong

35. My interest in spiritual practices is: none, slight, medium, strong

SELF-CARE

36. Times I wear clean clothes: rarely, sometimes, often, always

37. Times I get a good night sleep: never, rarely, sometimes, often, always

38. Times I feel rested: never, rarely, sometimes, often, always

39. Times I eat good food: rarely, sometimes, often, always

40. Times I wash my face and hands: rarely, sometimes, often, always

41. Times I clean my teeth: rarely, sometimes, often, always

PHYSICAL FUNCTIONING

43. Times I feel healthy and energetic: never, rarely, sometimes, often, always

44. Times I feel strong enough to work: never, rarely, sometimes, often, always

45. Times I can walk strong and fast: never, rarely, sometimes, often, always

DANGEROUS BEHAVIOR

46. Times I hang around people who are a bad influence: never, rarely, sometimes, often, always

Who: 1- Friends, 2- Family,3- Drug dealers 4- Co-workers

47. Times I have thoughts of being with drinking buddies: never, rarely, sometimes, often, always

48a.Times I get into arguments with my spouse: never, rarely, sometimes, often, always

48b.Times these arguments end in fights: never, rarely, sometimes, often, always

48c.Times these arugments/ fights are drinking-related: never, rarely, sometimes, often,always

49. Times I feel like hurting myself: never, rarely, sometimes, often, always

50. Times I get violent against others: never, rarely, sometimes, often, always

51. Times I think suicidal thoughts: never, rarely, sometimes, often, always

52. Times I actually attempted suicide over the past 6 months: never, rarely, sometimes, often, always

SOCIAL FUNCTIONING

53. Times I work towards getting close to my family: never, rarely, sometimes, often, always

54. Times I work towards getting close to my friends: never, rarely, sometimes, often, always

55. Times I work towards getting close to my clan relatives: never, rarely, sometimes, often, always

56. Times I take care of my family: never, rarely, sometimes, often, always

57. Times I take care of my friends: never, rarely, sometimes, often, always

58. Amount of time spent with drinking buddies: never, rarely, sometimes, often, always

59. Amount of time spent with friends: never, rarely, sometimes, often, always

60. Amount of time spent with family: never, rarely, sometimes, often, always

62. Times I have a devoted relationship with my spouse or boyfriend/girlfriend: never, rarely sometimes, often, always, NA

63. Times I treat this person with respect and support: never, rarely, sometimes, often, always NA

64. Times my spouse/boyfriend/girlfriend treats me with respect and support: never, rarely, sometimes, often, always, NA

65. Times I am capable of giving anyone love, respect, and support: never, rarely, sometimes, often, always

66. Times I feel ready for a strong, devoted relationship with a spouse/girlfriend/boyfriend never, rarely, sometimes, often, always

67. Time spent using illegal drugs: never, rarely, occasionally, often, whenever I can
What: 1- Marijuana 2- Coke

68. Have you been in detox over the past 6 months? Yes, No

69. Have you been in treatment over the past 6 months? Yes, No
If yes, where?

70. Have you had contacts with the police over the past 6 mos. due to drinking? Yes, No

70a. If yes, how many days did you spend in jail:

70b. How many DWI arrests have you had:

70c. Are you currently on probation or parole for a drinking-related problem? Yes, No

70d. Are you waiting charges (bench warrant), trial or sentencing? Yes, No

70e. Have you taken action to solve any legal problems? Yes, No

71. Times I want to drink: never, rarely, occasionally, often, whenever I can

72. Time spent drinking alcohol: never, rarely, occasionally, often, whenever I can

73. Times when my desire to stop drinking is strong: never, rarely, occasionally, often, always

74: Times when my control over alcohol is strong: never, rarely, occasionally, often, always

75. How would you classify your drinking behavior over the past 6 months? 1- Heavy drinking, 2- Weekend or binge drinking/Getting drunk when drinking, 3- Light drinking/Not getting drunk, 4- Rarely drinking, 5- No drinking at all

76. Is drinking currently affecting your: job, self, spouse, family, friends, health, police, finances, nothing, spirituality

77. On a scale of 1 to 10, where would you place your current drinking behavior, with 10 being no drinking?

A lot of drinking, 1-----------------5-------------------10,No drinking

78. If drinking at all, what triggers your drinking? 1- Peer pressure, 2- Social problems, 3- Interpersonal problems, 4- Finances, 5- PTSD/Vet experiences

79. What was the most helpful thing about the Eagle Plume program?

80. Did Eagle Plume teach you how to control your drinking? Yes, No

81 What did you need that you didn’t get?

82. Were the traditional teachings useful to you? Yes, No

83. If yes, how were the traditional teachings useful to you?

83a. Did you regain your sense of cultural identity through Eagle Plume? Yes, No

84. What is needed in the traditional area to improve the program?

85. What other changes would you recommend to improve Eagle Plume?

86. What areas of your life have improved since graduating from Eagle Plume?

87. Did you receive enough information about Eagle Plume services? Yes, No

88. Would you recommend this program to a friend or relative? Yes, No

89. How would you rate the Eagle Plume program overall

? Poor, 1-----------------5-------------------10,Excellent

89a. Did you attend weekend outpatient activities at NCI? Yes, No

89b. Please rate these services from 1-10:

Poor, 1-----------------5------------------10,Excellent

89c. Did you receive home or community-based NCI continuing care services? Yes, No

89d. Did you update your continuing care plan? Yes, No

89e. Were activities planned in order of importance? Yes, No

89f. Were follow-ups done as planned? Yes, No

89g. Were referrals made? Yes, No

89h. Please rate these aftercare services from 1-10:

Poor,1----------------5------------------10,Excellent

89i. What is needed to make these aftercare services better for you and your family?

90. Is there anything we can do to help you now? Please know that you are encouraged to come back to Eagle Plume.

___________________________ ___________________________________

Relative’s signature Interviewer’s signature

Time completed:

Place of interview:

INTERVIEWER CONFIDENCE

Level of Relative’s cooperation:

poor,1---------------------5------------------------10,Great

Overall confidence in this information:

Low,1---------------------5------------------------10,High

If below 10, why?

Ways in which this information was corroborated:

ASI Administered: Yes, Not completed, Refused:

Was a continuing care plan developed prior to graduation? Yes, No

Were activities prioritized? Yes, No

Was the original continuing care plan signed by the relative? Yes, No

Were follow-up plans signed by the counselor and the relative? Yes, No

Field Notes

GAF SCORE: REV 3-14-00

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Copyright © 2005 Na' Nizhoozhi Center Inc.
Last modified: May 24, 2005