LiUNA Local 1059 & Local 1089 GAIN Screener

Thank you for connecting with Addiction Services and for completing the initial intake form. This short screener is the second step of our intake package and must be completed. Once completed an EAP intake counsellor will call you within 24 business hours to complete the process and get you connected with services.

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The following questions are about common psychological, behavioural, and personal problems. These problems are considered significant when you have them for two or more weeks, when they keep coming back, when they keep you from meeting your responsibilities, or when they make you feel like you can’t go on. After each of the following questions, please tell us the last time, if ever, you had the problem by answering whether it was in the past month, 2 to 3 months ago, 4 to 12 months ago, 1 or more years ago, or never. 4 = Past month 3 = 2 to 3 months ago 2 = 4 to 12 months ago 1 = 1+ years ago 0 = Never

When was the last time that you had significant problems with:*

feeling very trapped, lonely, sad, blue, depressed or hopeless about the future?

When was the last time that you had significant problems with:*

sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day?

When was the last time that you had significant problems with:*

feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen?

When was the last time that you had significant problems with:*

becoming very distressed and upset when something reminded you of the past?

When was the last time that you had significant problems with:*

thinking about ending your life or committing suicide?

When was the last time that you had significant problems with:*

seeing or hearing things that no one else could see or hear or feeling that someone else could read or control your thoughts?

Reminder:

After each of the following questions, please tell us the last time, if ever, you had the problem by answering whether it was in the past month, 2 to 3 months ago, 4 to 12 months ago, 1 or more years ago, or never. 4 = Past month 3 = 2 to 3 months ago 2 = 4 to 12 months ago 1 = 1+ years ago 0 = Never

When was the last time that you did the following things two or more times?*

Lied or conned to get things you wanted or to avoid having to do something.

When was the last time you did the following things two or more times?*

Had a hard time paying attention at school, work, or home.

When was the last time you did the following things two or more times?*

Had a hard time listening to instructions at school, work or home.

When was the last time you did the following things two or more times?*

Had a hard time waiting for your turn.

When was the last time you did the following things two or more times?*

Were a bully or threatened other people.

When was the last time you did the following things two or more times?*

Started physical fights with other people.

When was the last time you did the following things two or more times?*

Tried to win back your gambling losses by going back another day.

Reminder:

After each of the following questions, please tell us the last time, if ever, you had the problem by answering whether it was in the past month, 2 to 3 months ago, 4 to 12 months ago, 1 or more years ago, or never. 4 = Past month 3 = 2 to 3 months ago 2 = 4 to 12 months ago 1 = 1+ years ago 0 = Never

When was the last time that:*

you used alcohol or other drugs weekly or more often?

When was the last time that:*

you spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or recovering from the effects of alcohol or other drugs (e.g., feeling sick)?

When was the last time that:*

you kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people?

When was the last time that:*

your use of alcohol or other drugs caused you to give up or reduce your involvement in activities at work, school, home, or social events?

When was the last time that:*

you had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or you used any alcohol or other drugs to stop being sick or avoid withdrawal problems?

When was the last time that you:*

had a disagreement in which you pushed, grabbed, or shoved someone?

When was the last time that you:*

took something from a store without paying for it?

When was the last time that you:*

sold, distributed, or helped to make illegal drugs?

When was the last time that you:*

drove a vehicle which under the influence of alcohol or illegal drugs?

When was the last time that you:*

purposely damaged or destroyed property that did not belong to you?

Reminder:

After each of the following questions, please tell us the last time, if ever, you had the problem by answering whether it was in the past month, 2 to 3 months ago, 4 to 12 months ago, 1 or more years ago, or never. 4 = Past month 3 = 2 to 3 months ago 2 = 4 to 12 months ago 1 = 1+ years ago 0 = Never

When was the last time you had significant problems with: (note related to alcohol/drug use)*

missing meals or throwing up much of what you did eat to control your weight?

When was the last time you had significant problems with: (not related to alcohol/drug use)*

eating binges or times when you ate a very large amount of food within a short period of time and then felt guilty?

When was the last time you had significant problems with: (not related to alcohol/drug use)*

being disturbed by memories or dreams of distressing things from the past that you did, saw, or had happen to you?

When was the last time you had significant problems with: (not related to alcohol/drug use:*

thinking or feeling that people are watching you, following you, or out to get you?

When was the last time you had significant problems with: (not related to alcohol/drug use)*

videogame playing or internet use that caused you to give up, reduce, or have problems with important activities or people at work, school, home or social events?

When was the last time you had significant problems with: (not related to alcohol/drug use)*

gambling that caused you to give up, reduce, or have problems with important activities or people at work, school, home, or social events?

Do you have other significant psychological, behavioural, or personal problems that you want treatment for or help with?*

Thank you for completing this screener.

Once you hit submit the form you will automatically be directed to our Client Orientation Handbook, located on our website. We also welcome you to visit virtual Supportive Information Sessions page. There you will find access to online versions of a selection of Supportive Information Sessions. These sessions are helpful if you’re looking for additional support in between or in advance of sessions or groups with our clinicians.

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