mvc display pdf in view : Convert pdf to word to edit text online Library control class asp.net web page windows ajax Miller%20-%20Combined%20Behavioral%20Intervention%20Thearpist%20Manual28-part1262

39.  I would like to talk about my past.
Y
ES
N
O
40.  I would like help in getting motivated to change.
Y
ES
N
O
41.  I would like for my spouse (or someone close to me) to come to treatment with me.
Y
ES
N
O
42.  I would like for my treatment to be short.
Y
ES
N
O
Form H  
William R. Miller & Janice M. Brown (1998)
Client # :_______________   
Therapist:_______________________ 
Personal Rulers Worksheet
Importance Ruler 
0              1              2              3              4              5              6              7              8              9             10 
Not at all              Somewhat                    Fairly                     Important                     Very                Extremely  
important               important                 important                                                  important              important
Confidence Ruler
0              1              2              3              4              5              6              7              8              9             10 
Not at all              Somewhat                    Fairly                     Confident                   Very                    Certain 
confident               confident                  confident                                                   confident                           
Readiness Ruler
0              1              2              3              4              5              6              7              8              9             10 
Not at all              Somewhat                    Fairly                     Ready                        Very               Completely  
ready                      ready                          ready                                                       ready                    ready
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Form I
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Client # :_______________   
Therapist:_______________________ 
Decisional Balance Worksheet
Cons (Reasons Not to Change)   
Pros (Reasons to Change) 
Good things about continuing to drink as before
Not-so-good things about drinking 
Not-so-good things about changing my drinking
Good things about changing my drinking
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Form J
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Client # :_______________   
Therapist:_______________________ 
AASE-T
Listed below are a number of situations that lead some people to drink.  How tempted may you be to drink in each 
situation?  Circle the number that best describes your feelings of temptation in each situation at the present time.   
Situation
Not at all 
tempted
Not very 
tempted
Moderately 
tempted
Very  
tempted
Extremely 
tempted
1.  When I am in agony because of stopping or       
withdrawing from alcohol use
1
2
3
4
5
2.  When I have a headache
1
2
3
4
5
3.  When I am feeling depressed
1
2
3
4
5
4.  When I am on vacation and want to relax
1
2
3
4
5
5.  When I am concerned about someone
1
2
3
4
5
6.  When I am very worried
1
2
3
4
5
7.  When I have the urge to try just one drink and see what    
happens
1
2
3
4
5
8.  When I am being offered a drink in a social situation
1
2
3
4
5
9.  When I dream about taking a drink
1
2
3
4
5
10.  When I want to test my willpower over drinking
1
2
3
4
5
11.  When I am feeling a physical need or craving for 
alcohol
1
2
3
4
5
12.  When I am physically tired
1
2
3
4
5
13.  When I am experiencing some physical pain or injury
1
2
3
4
5
14.  When I feel like blowing up because of frustration
1
2
3
4
5
15.  When I see others drinking at a bar or a party
1
2
3
4
5
16.  When I sense everything is going wrong for me
1
2
3
4
5
17.  When people I used to drink with encourage me to         
drink
1
2
3
4
5
18.  When I am feeling angry inside
1
2
3
4
5
19.  When I experience an urge or impulse to take a drink      
that catches me unprepared
1
2
3
4
5
20.  When I am excited or celebrating with others
1
2
3
4
5
Form K  
Carlo C. DiClemente, Department of Psychology, University of Maryland Baltimore County
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Client # :_______________   
Therapist:_______________________ 
New Roads Work Sheet
Triggers
Effects
Form L
Client #: _______________   
Therapist:_______________________ 
Personal Happiness Form
Life Areas
How happy or satisfied are you with each of these areas of your life?   
(Circle only one number for each item) 
Completely     Somewhat      Somewhat       Mostly        Completely           Doesn't 
Dissatisfied     Dissatisfied     Satisfied        Satisfied          Satisfied            Apply
Link 
Υ
Change
Υ
Friends and social life
       2        3        4        5        6        7        8        9        10           NA
1
Job/work
       2        3        4        5        6        7        8        9        10           NA
2
Where I live
       2        3        4        5        6        7        8        9        10           NA
3
Money, financial 
security
       2        3        4        5        6        7        8        9        10           NA
4
Education and 
Learning 
       2        3        4        5        6        7        8        9        10           NA
5
Leisure time and fun
       2        3        4        5        6        7        8        9        10           NA
6
Mood and self-esteem
       2        3        4        5        6        7        8        9        10           NA
7
Anger and arguments
       2        3        4        5        6        7        8        9        10           NA
8
Stress and anxiety
       2        3        4        5        6        7        8        9        10           NA
0
9
Physical health
       2        3        4        5        6        7        8        9        10           NA
10
Spirituality 
       2        3        4        5        6        7        8        9        10           NA
11
Love and affection
       2        3        4        5        6        7        8        9        10           NA
12
Family relationships
       2        3        4        5        6        7        8        9        10           NA
13
Relationship with 
spouse/partner 
       2        3        4        5        6        7        8        9        10           NA
14
Sexuality
       2        3        4        5        6        7        8        9        10           NA
15
Eating, weight
       2        3        4        5        6        7        8        9        10           NA
16
Physical activity, 
exercise
       2        3        4        5        6        7        8        9        10           NA
17
Giving/caring for 
others
       2        3        4        5        6        7        8        9        10           NA
18
Mental ability, 
memory
       2        3        4        5        6        7        8        9        10           NA
19
Personal safety, 
security
       2        3        4        5        6        7        8        9        10           NA
20
Completely     Somewhat      Somewhat       Mostly        Completely           Doesn't 
Dissatisfied     Dissatisfied     Satisfied        Satisfied          Satisfied            Apply
Form M
Personal Happiness Card Sort
Personal 
Happiness 
Card Sort
Friends and  
Social Life 
PH-01
11
Job/Work 
PH-02 
Where I Live 
PH-03 
Money and  
Financial Security 
PH-04
Education and Learning
PH-05 
Leisure Time and Fun 
PH-06 
Mood and Self-Esteem 
PH-07 
Anger and Arguments 
PH-08 
Stress and Anxiety 
PH-09 
Physical Health 
10 
PH-10 
Spirituality 
11 
PH-11 
Love and Affection 
12
Family Relationships 
13
Relationship with 
Spouse/Partner 
14
Sexuality 
15 
PH-15 
15
Eating and Weight 
16 
PH-16
Physical Activity  
and Exercise 
17 
PH-17
Giving/Caring  
for Others 
18 
PH-18 
Mental Ability  
and Memory 
19 
PH-19
Personal Safety 
and Security 
20 
PH-20
YES
NO
Form N
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Client #: 
_____________
__    
Options 
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