Do I Have a Problem?

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.