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PROFESSIONAL ALCOHOL ASSESSMENT

Take our confidential assessment and provide honest answers to the following questions below to help determine if you are dependent on alcohol or have a substance abuse problem.
1.) Are you happy with the way your life is going?*
- Yes
- No
2.) Do you use drink to escape your problems?*
- Yes
- No
If YES: Which feelings/emotions do you experience that you choose to use alcohol to help cope with? Check off all boxes that apply:*
- Depression
- Anxiety
- Fear
- Anger
- Guilt
- None of the above
3.) Is drinking affecting your reputation?*
- Yes
- No
4.) Is drinking causing problems with your job or affecting you financially?*
- Yes
- No
5.) Have your relationships been negatively affected because of drinking?*
- Yes
- No
6.) Has alcohol resulted in legal problems (DUI/DWI/OTHER)?*
- Yes
- No
7.) Have you ever been hospitalized because of drinking, or has alcohol affected your physical health in any way, such as liver problems, high blood pressure or stroke?*
- Yes
- No
8.) Have you ever experienced irregular shaking or tremors in your hands or body after heavy drinking or during periods without having a drink?*
- Yes
- No
9.) Do you refuse to go places where you cannot drink, or do you need to drink to have fun socially?*
- Yes
- No
10.) Do you lie about your drinking or hide alcohol from family/friends?*
- Yes
- No
11.) Do you drink alone?*
- Yes
- No
If YES, how often do you drink alone?*
- Every Day
- Several Times Per Week
- A Few Times Per Month
- Once in a Whole
12.) Can you stop drinking after one glass?*
- Yes
- No
13.) Do you ever crave alcohol?*
- Yes
- No
14.) Do you ever experience memory loss from drinking?*
- Yes
- No
15.) Which response below best describes your current feeling towards your use of alcohol?*
- I’m ready to get help today
- I know I need to stop drinking, just not sure how
- I know I need to stop drinking, just not sure I’m ready
- I don’t know if I have a problem, but I might
- I don’t think I have a problem with alcohol
- If other, please describe:
*
For your confidential results, please provide the following information below and complete the Professional Alcohol Assessment:
Name*
First Last
Phone*
Email*

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RESIDENTIAL TREATMENT CENTER

16286 S. Sunland Gin Rd
Arizona City, AZ 85123

OUTPATIENT TREATMENT CENTER

2325 W Guadalupe Rd STE 107,
Gilbert, AZ 85233

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