Substance Use Questionnaire

Do you struggle with limiting the length of time or limiting the amount of substance you use?

YesNo

Do you struggle with stopping or reducing your substance use?

YesNo

Do you spend a lot of time getting substances or recovering from the effects of substances (such as being hungover or sleeping)?

YesNo

Do you experience an intense desire or craving to use the substance(s)?

YesNo

Have you experienced difficulties taking care of responsibilities at work or in the home (such as keeping up with work tasks or housework or paying the bills)?

YesNo

Have you experienced problems with family or friends because of your substance use?

YesNo

Have you given up hobbies or activities you previously enjoyed because of your substance use?

YesNo

Have you continued to use substances in physically harmful situations or engage in activities that could cause you harm (examples include, but are not limited to: theft, driving while under the influence, or sharing needles)?

YesNo

Do you experience health-related problems (such as heart problems or tooth decay) that are caused or made worse by your substance use?

YesNo

Do you experience mental health problems (such as depression or anxiety) that are caused or made worse by your substance use?

YesNo

Do you find yourself having developed tolerance (either needing more of the substance to experience the same effect or experiencing less of the effect with the same amount)?

YesNo

Do you experience withdrawal side effects when you are not using substances (such as moodiness, depression, anxiety, cravings, difficulty sleeping or eating)?

YesNo

Out of 12 Questions, the # of times "Yes" was answered is:

If this survey has helped you determine that you want to pursue substance-related Counseling, please contact us

HERE

We look forward to hearing from you!