Forms and Documents
Welcome to the Healthy Lifestyles Guided Self-Change resource library. This page provides access to a variety of forms, handouts, and exercises used in the evidence-based Guided Self-Change (GSC) treatment. The GSC treatment has been recognized by the American Psychological Association Division 12 (Society of Clinical Psychology) as an Empirically Supported Treatment.
Many of these resources [any items with this symbol (†)] are also featured in the book, Group Therapy for Substance Use Disorders: A Motivational Cognitive-Behavioral Approach,” by Linda and Mark Sobell, which offers detailed guidance on their use.
Brief Situational Confidence Questionnaire (BSQC)
The BSCQ is a state dependent measure that assesses self-confidence to resist the urge to drink heavily or use drugs in a variety of situations.
Get More Information on the BSCQ- Appendix D. Brief Situational Confidence Questionnaire - Alcohol & Drug Use (PDF)
- BSCQ General Form (PDF)
- BSCQ Blank (PDF)
- Table 4.2 - BSCQ eight categories of high-risk situations and shorthand names of profiles (PDF) †
- BSCQ All Graphs (PDF)
- BSCQ Color Graphing Program v6 (XLS)
- BSCQ Graphing Program v6 (XLS)
- BSCQ Profiles (PDF)
- BSCQ Drugs Translated Traditional Chinese (PDF)
GSC Handouts
- Client Handout 3.1 - Decisional Balance Exercise (PDF) †
- Client Handout 3.2 - Self-Monitoring Logs for Alcohol Use (PDF) †
- Client Handout 3.3 - Self-Monitoring Logs for Drug Use (PDF)†
- Client Handout 3.4 - Abstinence Goal Evaluation for Alcohol or Drugs (PDF) †
- Client Handout 3.5 - Goal Choice Evaluation for Alcohol Use (PDF) †
- Client Handout 3.6 - Where Are You Now Scale (PDF) †
- Client Handout 4.1 - Personalized Feedback Where Does Your Alcohol Use Fit In - Individual and Group Session 1 (PDF) †
- Client Handout 4.2 - Personalized Feedback Where Does Your Drug Use Fit In - Individual and Group Session 1 (PDF) †
- Client Handout 4.3 - Example of Personalized Alcohol Use Feedback Pretreatment to Session 4 (PDF) †
- Client Handout 4.4 - Example of Personalized Drug Use Feedback Pretreatment to Session 4 (PDF) †
- Client Handout 4.5 - Reading on Identifying Triggers Individual and Group Session 2 (PDF) †
- Client Handout 4.6 - Exercise on Identifying Triggers (PDF) †
- Client Handout 4.7 - Sample BSCQ Alcohol or Drug Use Profile from the Assessment Session 2 (PDF) †
- Client Handout 4.8 - Exercise on Developing New Options and Plans (PDF) †
- Client Handout 4.9 - Sample BSCQ Alcohol or Drug Use Profile from the Assessment and Session 3 - Individual and Group Session 4 (PDF) †
- Client Handout 5.1 - Introduction to Groups (PDF) †
Handouts
- Therapist Handout 3.1 - Assessment Session for GSC Group and Individual Therapy (PDF) †
- Therapist Handout 3.2 - Timeline Followback Instructions, Standard Drink Chart, and Sample Calendar for Alcohol Use (PDF) †
- Therapist Handout 3.3 - Timeline Followback Instructions and Sample Calendar for Drug Use (PDF) †
- Therapist Handout 4.1 - Individual Session 1 (PDF) †
- Therapist Handout 4.2 - Individual Session 2 (PDF) †
- Therapist Handout 4.3 - Individual Session 3 (PDF) †
- Therapist Handout 4.4 - Individual Session 4 (PDF) †
- Therapist Handout 5.1 - Group Session 1 (PDF) †
- Therapist Handout 5.2 - Group Session 2 (PDF) †
- Therapist Handout 5.3 - Group Session 3 (PDF) †
- Therapist Handout 5.4 - Group Session 4 (PDF) †
Summaries and Feedback Materials
- Appendix C. Drug Use History Questionnaire (DUHQ) (PDF) †
- Summary of Outcome Studies using the Guided Self-Change Treatment Model (PDF) †
- Table 4.1 - Personalized feedback materials given to clients during Session 1-4 (PDF) †
- Mt. Change (PDF)
- DAST10 Form Scoring Feedback (PDF)
- AUDIT Form Scoring Feedback (PDF)
- Use this program to create Client Handout 4.3 which is the Personalized Alcohol Use Feedback of the client’s drinking from Pretreatment to Session 4 (XLS) †
- Use this program to create Client Handout 4.4 - Example of Personalized Drug Use Feedback Pretreatment to Session 4 (XLS) †
Program-Specific Forms
Articles
- Comparison of a Quick Drinking Screen with the Timeline Followback for Individuals with Alcohol Problems (PDF)
- Comparison of the Quick Drinking Screen and the Alcohol Timeline Followback with Outpatient Alcohol Abusers (PDF)
- A Quick Drinking Screen for Identifying Women at Risk for an Alcohol-Exposed Pregnancy (PDF)
- Using One Question to Identify Women at Risk for an Alcohol-Exposed Pregnancy (PDF)
- Two Brief Measures of Alcohol Use Produce Different Results: AUDIT-C and Quick Drinking Screen (PDF)
- Using a Single Binge Drinking Question to Identify Russian Women at Risk for an Alcohol-Exposed Pregnancy (PDF)
Drug History Questionnaire (DHQ)
Quick Drinking Screen (QDS)
- 2020 QDS Instructions and References (doc)
- QDS Spanish (doc)
Self-Monitoring Logs
- Aids For Changing Your Drinking On Your Own (PDF)
- Healthy Lifestyles - Path to Healthy Living Manual (PDF)
- Decisional Balance Eating (PDF)
- Drug Interactions - NIAAA - Publications (PDF)
- Family Tree Overview (doc)
- Family Tree Form (doc)
- Moderation Evaluation (doc)
- Rethink Your Drink flyer (PDF)
- Rethink Your Drink - Poster (PDF)
- Rethink Your Drink - How Much Sugar - Poster (PDF)
- Rethink Your Drink - Sodas: Are You Pouring on the Pounds (PDF)
- Rethink Your Drink - Water Recipes (PDF)
- A1- Confidence & Importance (DOC)
- A2- Smoking Self-Monitoring Logs (DOC)
- 1A- Smoking Decisional Balance Exercise (DOC)
- 1B- Smoking Timeline (PDF)
- 1C- Smoking Withdrawal (DOC)
- 1D- Smoking Pie Charts (PDF)
- 2A- Smoking Information (DOC)
- 2B- Effects Of Smoking (DOC)
- 2C- Costs (DOC)
- 2D- Quit Date (DOC)
- 2E- Puffs Chart (PDF)
- 3A- Coping With Triggers (DOC)
- 3B- Beverage Calories
- 3B- Weight Gain (PDF)
- 3C- Weight Gain 02 (PDF)
- 4A- Good-Bye Exercise (DOC)
- 4B- Confidence & Importance (DOC)
- 4C- Mt. Stay Quit (DOC)
- It's Never Too Late To Quit (PDF)
Motivational Interviewing
- Key Group Statements (PDF)
- Group Recruit Intro (PDF)
- Group Cohesion Scale (PDF)
- Motivational Techniques and Skills (PDF)
- Table 5.1 - Round-robin discussion topics used in the GSC group treatment (PDF) †
- Table 5.2 - Ways to bring different members and topics into group discussion (PDF) †
- Table 5.3 - Group rules and their rationales (PDF) †
- Weighted Decisional Balance Exercise (DOC)
Spanish Translations
Los siguientes archivos son traducciones al español de algunos de los formularios utilizados en la clínica Healthy Lifestyles Guided Self-Change.- Manual de autoayuda para personas con problemas en su forma de beber (PDF)
- AUDIT Español (DOC)
- Cuestionario Breve de Consumo de Bebidas (DOC)
- Cuestionario Breve de Consumo de Bebidas (PDF)
- DAST Español (DOC)
- Registros de Automonitoreo (DOC)
- AUDIT Retroalimentación (PDF)
- DAST Retroalimentación (PDF)
- Muestra del Cuestionario Breve de Consumo de Bebidas (PDF)
- Cuestionario Breve de Consumo de Bebidas en Blanco (PDF)
- Instrucciones, Calendario de Muestra y Conversiones de Bebidas Estándar de la TLFB (PDF)
- Balance Decisional Ponderado en Español (DOC)
- Cuestionario Rápido de Consumo de Alcohol (QDS) y Referencias en Español (DOC)
Contact Us
Jessica J. Ruiz, PsyD, ABAP | Clinic Director
In-person and telehealth services available
(954) 262-5922
Nova Southeastern University
Psychology Services Center
Maltz Psychology Building
3151 College Avenue
Davie, FL, 33314