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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*
First Last
Phone*
Email*

PROFESSIONAL SUBSTANCE ABUSE ASSESSMENT