1.  Do you find yourself drinking (or using drugs) more than 3 times per week or

until too intoxicated or impaired to function normally?

Yes No

2.  Do you use prescription medication more often, or in stronger doses than prescribed,

or when you don’t really have the symptoms it was prescribed for?

Yes No

3.  Have you ever done something (such as having sex, getting into a fight, or other behaviors)

while using, that you would not have done if you were sober

or weren’t under the influence of drugs or medication?

Yes No

4.  Are you pre-occupied with, or do you look forward to drinking,

taking prescription or illicit drugs throughout the day?

Yes No
 

5.  Does it take more alcohol or drugs to acquire the same feeling or “high” than it used to?

Yes No

 
6.  Is it difficult for you to stop using or drinking once you’ve started?

Yes No

7.  Have you had to call in sick at work, or miss school,

because you were feeling sick after drinking or using drugs?

 Yes No

8.  Have you lost work (been fired or told you weren’t needed anymore),

or dropped classes at school because of your drinking or using drugs?

 Yes No

9.  Has your family, work, social, or spiritual life been affected by

your drinking or use of medication or drugs?

 Yes No

 
10.  Has anyone you know ever told you that they think you have a problem with

drinking too much or overusing prescription medication or drugs?

Yes No

11.  Have you ever had any legal problems as a result of your drinking or drug use
(including driving under the influence)?

Yes No

12.  Have you ever promised yourself or others that “This is the last time”?

Yes No

13.  Have you ever failed to keep this promise?

Yes No

14.  Do you justify your drinking with “I’m stressed” or “I can’t sleep” or

 “It’s just a little something to calm me down”?

Yes No

 
15.  Have you ever felt suicidal or that you wanted to hurt yourself or someone else

while drinking, using or because of using or drinking?

Yes No

16.  Do you sometimes feel as though you want to stop

or reduce your alcohol or drug use and then don’t seem to be able to?

Yes No

 
17.  Have you lost work or had troubled relationships with your friends or family

because of situations involving your drinking or drug use?

Yes No

18.  Are you feeling moody, angry or sad, or withdrawing from

your relationships or normal activities?

  Yes No

19.  Do you feel as if you have lost hope in being able to live the full,

productive and happy life you want?

  Yes No

If you have answered Yes to some of these questions

your loved one may be experiencing a certain level of addiction.  

We would like to help you determine what type of services or referral they need. 

We would also like to assist you or provide appropriate referrals

if you are struggling with your relationship

with them or others due to their behavior.

Please contact our Assessment Specialist at (386) 736-0420.  

Or, if you wish, please provide us with some contact information ...

even if only your e-mail address.  

Please know that we are not a crisis center

and we do not check our email every day (especially on weekends),

so if you are in our area and in crisis,

please call our local hot line for immediate assistance.

The phone number is 1-888-516-2296.  

If you or your loved one feels suicidal or the desire to hurt someone,

please call 911 to get help. 

There are people in every community who care

and want to help you and your family get well

and live the productive, happy life you deserve.  

If you live outside central Florida and your community has this service,

please call 211 for available community resources.