Self-Assessment for Drug and Alcohol Treatment Have you ever done something that you regretted under the influence of drugs or alcohol? Yes No Have you ever lied to anyone about your drug use? Yes No Do you feel the need to be under the influence of drugs and/or alcohol during normal activities? Yes No Have you ever experienced blackouts or periods of memory loss from drugs or alcohol? Yes No Do you rely on drugs and alcohol for confidence in social situations? Yes No Have you ever been arrested or almost arrested, gotten a DWI, MIP, or a ticket for drugs, alcohol or paraphernalia? Yes No Does it take more drugs or alcohol than it used to for you to get high or drunk? Yes No Have you ever overdosed or had alcohol poisoning? Yes No Do you spend a lot of time planning, talking about, thinking about, or trying to get drugs and alcohol? Yes No Have you ever tried a drug that you said you wouldn’t? Yes No Has your school or work performance declined? Yes No Has your relationship with your parents changed since you started using drug and or alcohol? Yes No Have you ever promised yourself or someone else that you would stop using or cut down and not followed through? Yes No Has drinking or drug use caused arguments or problems between you and your family, friends, school or work? Yes No Have you ever lost friends or romance due to your drinking or using? Yes No Have you engaged in risky sexual behavior while on drugs or alcohol? Yes No Have you ever missed an important event because of your drinking or using? Yes No Have you stolen from anyone including friends or family to support your alcohol/ drug use? Yes No Have you ever sought out help, voluntarily or forced, because of your drinking or drug use? (Counselors, A.A., N.A., or treatment for drugs and alcohol) Yes No Do you drink or use more than you intended to or at times when you know you shouldn’t? Yes No This field is hidden when viewing the formTotal
