CHILD’S NAME PARENT’S NAME WORKER’S NAME DATE COMPLETED CLIENT

Child’s Name

Parent’s Name

Worker’s Name

Date Completed

Client Number

Audit - Scoring

Question 1

Question 2

Question 3

Question 4

Question 5

Question 6

Question 7

Question 8

Question 9

Question 10

Total Score

A score of 8 or more indicates a strong likelihood of Hazardous or harmful alcohol consumption

A score of 20 or more indicates dependent drinking, and appropriate further assessment.

Comments – Actions

Readiness to Change - Scoring

Strongly Disagree

- 2

Disagree

- 1

Unsure

- 0

Agree

+ 1

Strongly Agree

+ 2

Pre-contemplation

Contemplation

Action

Item Number

Score

Item Number

Score

Item Number

Score

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Total

Total

Total

To calculate the score for each scale, simply add the item scores for the scale in question. The range of each scale is -10 through 0 to +10. A negative scale score reflects an overall disagreement with items measuring the stage of change, whereas a positive score represents overall agreement. The highest scale score represents the Stage of Change Designation.

Note: If two or more scale scores are equal, then the scale farther along the continuum of change (Pre-contemplation-Contemplation-Action) represents the subjects’ Stage of Change Designation. For example, if a subject scores 6 on the Pre-contemplation scale, 6 on the Contemplation scale and – 2 on the Action scale, then the subject is assigned to the Contemplation stage.

If one of the five items on a scale is missing, the subjects’ score for that scale should be pro-rated (i.e. multiplied by 5/4 or 1.25). If two or more items are missing, the scale score cannot be calculated. In this Stage of Change Designation will be invalid.

Comments – Actions