M. Dennis Paul, Ph.D. | Professional Conflict Management Services-------------------- Thought Addiction Specialist

Workshop Enrollment Survey

Please complete the following survey and submit to: M. Dennis Paul, Ph.D. either by clicking the submit button at the end or through the regular mail

16 Topaz Drive
Nashua, NH 03062

or by email (copy and paste to your email message)

mdp54@comcast.net

It is important that all questions be answered completely and honestly. Your submission is considered consent to process and respond and is also considered consent to schedule an exclusive workshop for you. Should you have any questions or concerns prior to completing the survey, please e-mail to the above. You may also call 1-603-888-1135 , however, response time is slower by this method.

Name (use first name and last initial if you prefer) E-Mail Address Phone # Other sources of contact (agent, ceo, friend, etc. Date of birth Gender In your own words, briefly describe what you believe to be your genuine addictions
How long do you believe this/these addiction(s) has/have been active? List all the people, businesses, or other associations who you believe have been effected by your addiction(s)
How much money do you estimate is spent by you each year to maintain your addiction(s) and what was or is the source of this money? How many times have you attempted to control this/these addiction(s) and what method(s) did you employ?
What is the longest time you have been able to control this/these addiction(s) and when was this? Using (1) as the lowest (not concerned) and (10) as the highest (extremely concerned), please rate the following.....Your addiction(s) effect(s) on you physically Mentally Socially Monetarily Past relationships Present relationships Future relationships Job, craft, work, art, etc Using the same scale as above, please rate the following.... How important do you feel it is you begin work on overcoming your addiction(s) now? How important do you feel family thinks it is that you begin? Friends? Boss, agent, client,.....? What do you know about your addiction(s)?
What would you like to learn regarding your addiction(s)?
What do you want to occur as a result of enrolling in either the 14 or 21 day addictions workshops

Using the following scale, please rate the statements below.

1=not important

2=moderately important

3=important

4=extremely important

I should know everything I should be like everyone else I should never make mistakes I should never offend The more money I have, the smarter and more important I am I should always be advancing in my career My home should always be neat and clean I should do everything myself I should always be cheerful If it is to be done right it must be done my way I should be doing something constructive at all times I should never lose my temper I shouldn't rest until it is all done Others should know how I feel I should always be there when others need me I must maintain an image of strenth and invulnerability I must relax when I am tired or stressed I must be myself at all times My actions and behaviours are the main cause of others' emotions Others' behaviours and actions are the main cause of my emotions If someone close to me is hurt or in trouble, it is my responsibility to make things better People must agree with what I think if we are to be friends I am bothered when others do not find me attractive, pleasant, friendly, sincere, etc I prefer that others do things my way When confronting a problem, do you see a needed response as having to black or white or do you look for gray areas? Do you believe that recovery means all or nothing? When someone makes a statement to you, do you often feel that they are implying something which was not actually stated? If your parents and siblings had been more loving, do you feel you would be happier today? Please name all the emotions you know
How often do you feel depressed and how long does this feeling usually last? When was the last time you felt proud and what was the reason?
How many times were you aware of feeling angry in the last two weeks? How many times were you aware of feeling hurt in the last two weeks? Lonely? Anxious? Bored? Confused? Exhausted? Happy? Hopeless? Loved? Optomistic? Sad? How do you feel at this moment? If you were accepted as a client in either a 14 or 21 day addictions workshop, what special accomodations would you demand?
Which program do you feel would best serve your needs...14 day or 21 day? Please tell me anything you feel is important for me to know regarding yourself, your addiction(s), your health, profession, lifestyle, desire to create your own working recovery program, or anything else suitable.