Drug Abuse Screening Test (DAST)

Choices Mental Health Counseling PLLC

Narrowsburg, NY 12764
Name

First NameLast Name
Today's Date:*

MonthDayYear
Date
Instructions: Please complete this form if you are here for an alcohol or substance abuse screening, assessment, treatment, or relapse prevention. If you are not here for that, please check the following box and submit.
If you are not here for any reason related to drugs and you feel that none of these pertain to you, please write "None of these apply" and submit below.
Drug Abuse Screening Test

(DAST)
1. Have you used drugs other than those required for medical reasons?

YesNo
2. Have you abused prescription drugs?

YesNo
3. Do you abuse more than one drug at a time?

YesNo
4. Can you get through the week without using drugs?

YesNo
5. Are you always able to stop using drugs when you want to?

YesNo
6. Have you had "blackouts" or "flashbacks" as a result of drug use?

YesNo
7. Do you ever feel bad or guilty about your drug use?

YesNo
8. Does your spouse (or parents) ever complain about your involvement with drugs?

YesNo
9. Has drug abuse created problems between you and your spous or your parents?

YesNo
10. Have you ever lost friends because of your use of drugs?

YesNo
11. Have you neglected your family because of drugs?

YesNo
12. Have you been in trouble at work (or school) because of drug abuse?

YesNo
13. Have you lost your job because of drug abuse?

YesNo
14. Have you gotten into fights when under the influence of drugs?

YesNo
15. Have you engaged inillegal activities in order to obtain drugs?

YesNo
16. Have you been arrested for possession of illegal drugs?

YesNo
17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

YesNo
18. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?

YesNo
19. Have you ever gone to anyone for help for drug problems?

YesNo
20. Have you been involved in a treatment program specifically related to drug abuse?

YesNo
Should be Empty:

Choices Mental Health Counseling PLLC

Drug Abuse Screening Test