In the following self-assessment, please answer the questions honestly either yes or no;

Drug of choice? (please select, required)

Is your using or drinking increasing in amount?
YesNo

Have you felt decrease in effect?
YesNo

Have you ever felt any withdrawal symptoms or shakes?
YesNo

Ever taken in larger amounts and for longer periods than intended?
YesNo

Any repeated unsuccessful attempt to quit?
YesNo

In the past have you been in trouble at school, work or with the law as a result of drinking or drug use?
YesNo

In the past year has your drug use or drinking caused problems at home with your family, children, parents or spouse?
YesNo

Use continues despite knowledge of adverse consequences or against professional advice?
YesNo

When drinking with other people, do you try to have a few extra drinks when others won’t know about it?
YesNo

Do you use or drink alone?
YesNo

Do you sometimes feel a little guilty about your drinking or using?
YesNo

Has a family member or close friend express concern or complained about your using/drinking?
YesNo

Have you been having more memory “blackouts” recently?
YesNo

Do you usually have a reason for the occasions when you use/drink heavily?
YesNo

When you’re sober, do you sometimes regret things you did or said while using/drinking?
YesNo

Have you sometimes failed to keep promises you made to yourself about controlling or cutting down?
YesNo

Do you try to avoid family or close friends while you are using/drinking?
YesNo

Have you ever gone to anyone for help?
YesNo

Have you experienced any seizures?
YesNo

Detox required?
YesNo

Your details:

Your Name (required)

Your Gender

Your Age (required)

Your Nationality (required)

Your Email (required)

Your Telephone Number (required)

Medical issues?

Personal issues?

Health issues?

Mental health diagnosis?

History of suicide?

Are you on any prescription medication?

Any other information?