Assessement Form
 
This Assessment is just a guide to help you determine if your loved one may be helped by an intervention.
These are tough questions, but if there is a problem, the first step to recovery is admitting it exists.
This assessment may save somebody's life.
 
  Please check the boxes that apply to your situation:
Self Assessment
Loved-one Assessment
 

Do you ever use alcohol or drugs alone?

 

Is your alcohol or drugs causing problems at home?

  

Have you ever experienced a blackout?

 

Have you ever lied to cover up your drug or alcohol use?

 

Do you ever have irrational fears?

 

Do you feel you can not have a good time without drugs or alcohol?

 

Do feel that nobody understands your problems?

 

Are you missing work or having trouble at work because of a problem with drugs or alcohol?

 

Does using alcohol or drugs interfere with your eating or sleeping?

 

Have you noticed a sudden loss of weight?

 

Have you ever taken drugs or alcohol simply for the effect?

 

Have you ever used drugs or alcohol because of stress or emotional pain?

 

Have you ever lied about what or how much you use?

 

Do you know if your loved-one ever uses alcohol or drugs alone?

 

Is your loved-one's alcohol or drugs causing problems at home?

  

Have your loved-one ever experienced a blackout?

 

Have you ever lied to cover up your loved one’s drug or alcohol use?

 

Does your loved one ever have irrational fears?

 

Does your loved one feel they can not have a good time without drugs or alcohol?

 

Does your loved one feel that nobody understands their problems?

 

Is your loved one missing work or having trouble at work because of a suspected problem with drugs or alcohol?

 

Does using alcohol or drugs interfere with your loved one’s eating or sleeping?

 

Have you noticed sudden loss of weight of your loved one?

 

Has your loved one ever taken drugs or alcohol simply for the effect?

 

Has your loved one ever used drugs or alcohol because of stress or emotional pain?

 

Has your loved one ever lied about what or how much they use?

 
         
  If you checked off any of these questions, you may have an addiction problem and may need professional help.  
  If you checked off any of these questions, your loved-one may have an addiction problem and may need professional help.  
         
  *=Required Field

*First Name:
 

Phone:

 

Best time to contact you:

 

*Your relationship to loved one:

 
*Email Address:
 
Substance(s) used