Assessment Survey

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Yes

No

1)

When you drink or use drugs do you tend to do so to the point of excess?

2)

Does it take a lot of effort to control your intake of drugs and alcohol?

3)

Has anyone said to you they think you have a problem with alcohol or drugs?

4)

Have you ever tried to hide or disguise your alcohol/drug use?

5)

Has drinking or drug use created problems for you in your personal relationships?

6)

Has drinking or drug use affected your work or school performance?

7)

Do you ever use alcohol or drugs to obtain a sense of relief?

8)

Has alcohol or drug use ever resulted in legal problems?

9)

Has drinking or drug use ever affected your financial well-being?

10)

Have you ever experienced memory lapses or "lost time" during an evening of drinking?

11)

Have you ever awakened and not remembered going to bed after drinking?

12)

Have you ever tried to stop drinking or using drugs on your own and rationalized returning to alcohol or drugs?

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