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Does Your Friend or Loved One Have an Addiction Problem?
Addiction Assessment
Name:
*
(At least your first name is required)
Email Address:
*
Phone Number:
*
Is your friend or loved one unhappy with their life direction?:
Yes
No
Do you feel they may have a problem with drugs/alcohol?:
Yes
No
Do they use drugs/alcohol continuously?:
Yes
No
Can they stop drinking after one glass?:
Yes
No
Do they drink alone?:
Yes
No
Is drinking/drug use affecting their reputation?:
Yes
No
Does drug/alcohol use cause problems with their job?:
Yes
No
Has drug/alcohol use negatively affected their relationships?:
Yes
No
Do they refuse to go places where they cannot use drugs/alcohol?:
Yes
No
Do they need to use drugs/alcohol to have fun socially?:
Yes
No
Do they do (or have they done) things that are illegal to get drugs/alcohol?:
Yes
No
Do they lie about their drinking?:
Yes
No
Do they use drugs/alcohol to escape their problems?:
Yes
No
Have they had medical problems from using drugs/alcohol?:
Yes
No
Has drug/alcohol use caused them legal problems?:
Yes
No
Do they have withdrawals when they cannot get drugs/alcohol?:
Yes
No
Do they use drugs/alcohol to cope with fear or anger or depression?:
Yes
No
Do you think they are willing and able to get treatment?:
Yes
No
Would you like more information about drugs/alcohol rehab from The River Source?:
Yes
No
