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Alcohol Abuse Assessment
Name:
*
(At least your first name is required)
Email Address:
*
Phone Number:
*
Are you unhappy with the way your life is going?:
Yes
No
Do you feel you may have a problem with alcohol?:
Yes
No
Are you preoccupied with thoughts of drinking?:
Yes
No
Can you stop drinking after one glass?:
Yes
No
Do you drink alone?:
Yes
No
Is drinking affecting your reputation?:
Yes
No
Is drinking causing problems with your job?:
Yes
No
Have your relationships been negatively affected?:
Yes
No
Do you refuse to go places where you cannot drink?:
Yes
No
Do you need to drink to have fun socially?:
Yes
No
Is drinking causing you financial difficulties?:
Yes
No
Do you hide alcohol from family or friends?:
Yes
No
Do you lie about your drinking?:
Yes
No
Do you drink to escape your problems?:
Yes
No
Do you drink to overcome shyness with other people?:
Yes
No
Has alcohol resulted in legal problems (DUI/DWI)?:
Yes
No
Do you worry that friends or family know you drink?:
Yes
No
Do you have memory loss from drinking?:
Yes
No
Do you ever crave alcohol?:
Yes
No
Do you drink to cope with fear or anger or depression?:
Yes
No
Are you willing and able to get treatment at The River Source?:
Yes
No
