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PROFESSIONAL SUBSTANCE ABUSE ASSESSMENT

By providing honest answers to this confidential assessment, The River Source can help evaluate your needs and give you some insight into whether or not you may have a problem with Drugs and/or Alcohol.

1.) Are you happy with the way your life is going?*

Yes
No

2.) Which option below best describes when you typically take your first drug or drink on most days?*

Within the first hour of waking up
Within a few hours of waking up
I usually wait until later in the day
Other

3.) Do you use drugs or drink alcohol to escape your problems?*

Yes
No

If YES: Which feelings/emotions do you experience that you choose to use drugs/alcohol to help cope with? Check off all boxes that apply:*

Depression
Anxiety
Fear
Anger
Guilt
None of the above

4.) Is drug/alcohol use affecting your reputation?*

Yes
No

5.) Are drugs/alcohol causing problems with your job or affecting you financially?*

Yes
No

6.) Which relationships have been affected because of your drug/alcohol use? Check off all boxes that apply:*

Spouse/Partner
Children
Other Family
Friends
None of the Above

7.) Have you ever been hospitalized because of your drug/alcohol use, or have either affected your physical health in any way, such as liver problems, high blood pressure or stroke?*

Yes
No

8.) Have you ever experienced physical withdrawal or signs of withdrawal during periods without using drugs/alcohol? Some common physical symptoms can be tremors, excessive sweating, feeling cold, nausea, vomiting, and fatigue.*

Yes
No

9.) Has anyone close to you in your life ever voiced their concern that you should get help for drinking/drug use?*

Yes
No

10.) What is your primary substance category of choice? Check off all boxes that apply:*

Heroin/Opiates
Alcohol
Stimulants (Cocaine, Meth, Adderall, Etc.)
Depressants (Xanax, Benzo, Valium, Etc.)
Other
I’d Rather Not Say

11.) Please choose one of the options below as it relates to pregnancy:*

I am currently pregnant
I am currently nursing or have an infant child
I am planning/considering pregnancy
None of the above

12.) Which response below best describes your current feeling towards your use of drugs/alcohol*

I’m ready to get help today
I know I need to stop, just not sure how
I know I need to stop, 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 drugs/alcohol
If other, please describe:

Untitled*

For your confidential results, please provide the following information below and complete the Substance Abuse Assessment:

Name*

Phone*

Email*