Tranquility Clinic Self-Assessment

1

Name* This field is required.

First Name

Last Name

2

Phone / WhatsApp Number* This field is required.

3

Is this on behalf of yourself or a loved one ?* This field is required.

For me

A loved one

4

Have you been concerned about your use of drugs, alcohol or prescription medication?* This field is required.

Yes

No

5

Have you experienced multiple hangovers or withdrawal symptoms?* This field is required.

Yes

No

6

Have family members, colleagues or friends expressed concern about your substance use?* This field is required.

Yes

No

7

Has your substance use affected your personal life, family life, social life, work or school performance?* This field is required.

Yes

No

8

Have you found yourself in harmful or risky situations because of your substance use?* This field is required.

Yes

No

9

Email

example@example.com

10

I consent to Tranquility Clinic contacting me about my results via phone, email or WhatsApp.* This field is required.

I agree