Do I Have a Problem?

Do you lose time from work due to drinking or drug use?

Yes
No

Is drinking or drug use making your home life unhappy?

Yes
No

Do you drink or use drugs because you are shy with other people?

Yes
No

Is drinking or drug use affecting your reputation?

Yes
No

Have you ever felt remorse after drinking or using drugs?

Yes
No

Have you ever gotten into financial troubles because of drinking or drug use?

Yes
No

Do you turn to lower companions and an inferior environment when drinking or using drugs?

Yes
No

Does your drinking or drug use make you careless of your family’s welfare?

Yes
No

Has your ambition decreased since drinking or using drugs?

Yes
No

Do you crave a drink or a drug at a definite time daily?

Yes
No

Do you want a drink or a drug the next morning?

Yes
No

Do you drink or use drugs to build up your self-confidence?

Yes
No

Has your efficiency decreased since drinking or using drugs?

Yes
No

Is drinking or using drugs jeopardizing your job or business?

Yes
No

Do you drink or use drugs to escape from worries or trouble?

Yes
No

Do you drink or use drugs alone?

Yes
No

Have you ever had a complete loss of memory as a result or drinking or drug use?

Yes
No

Has your physician ever treated you for drinking or drug use?

Yes
No

Does drinking or drug use cause you to have difficulty in sleeping?

Yes
No

Have you ever been to a hospital or institution on account of drinking or drug use?

Yes
No

Do you want to leave contact details so we can contact you?

Yes
No

Name*

First Last

Phone

Email

Do you want us to call you back?

Yes
No

Phone number for call back*

Name*

First name

Email*

We will send you a confirmation of your call back request to this email address.

Do I Have a Problem?

Do I have a problem?