• INTAKE: Self Alcohol/Drug Assessment

    INTAKE: Self Alcohol/Drug Assessment

  • Date*
     - -

  • Please answer all the following questions. All the information is kept in strict confidence and may not be disclosed without your permission. 

  • 4. How often do you drink or use?*
  • Date*
     - -

  • SIMPLE ASSESSMENT TOOL FOR AOD ABUSE

  • Date*
     / /
  • 1. Have you used alcohol or other drugs, such as wine, beer, hard liquor, pot, coke, heroin or other opiates, uppers, downers, hallucinogens, or inhalants in the past 6 months?*
  • 2. Have you felt that you use too much alcohol or other drugs in the past 6 months?*
  • 3. Have you tried to cut down or quit drinking or using alcohol or other drugs in the past 6 months?*
  • 4. Have you gone to anyone for help because of your drinking or drug use, such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, counselors, or a treatment program in the past 6 months?*
  • 5. Have you had any health problems in the past 6 months?*
  • If so*
  • 6. Has drinking or other drug use caused problems between you and your family or friends in the past 6 months?*
  • 7. Has your drinking or other drug use caused problems at school or work in the past 6 months?*

  • SIMPLE ASSESSMENT TOOL FOR AOD ABUSE, PAGE 2

  • 8. Other than this present DUl, have you been arrested or had other legal problems, such as bouncing bad checks, driving while intoxicated, theft, or drug possession in the past 6 months?*
  • 9. Have you lost your temper or gotten into arguments or fights while drinking or using other drugs in the past 6 months?*
  • 10. Are you needing to drink or use drugs more and more to get the effect you want in the past 6 months?*
  • 11. Do you spend a lot of time thinking about or trying to get alcohol or other drugs in the past 6 months?*
  • 12. When drinking or using drugs, are you more likely to do something you wouldn't normally do, such as break the rules, break the law, sell things that are important to you, or have unprotected sex with someone in the past 6 months?*
  • 13. Do you feel bad or guilty about your drinking or drug use in the past 6 months?*

  • The next questions are about your Lifetime experiences.

  • 14. Have you ever had drinking or other drug problems in your lifetime?*
  • 15. Have any of your family members ever had a drinking or drug problem in your lifetime?*
  • 16. Do you feel that you have a drinking or drug problem now in your lifetime?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • On submitting the form, the form(s) will be emailed directly to Jackson-Bibby.

  •  
  • Should be Empty: