1.  Is your adult friend, family member or loved one drinking, or using drugs more than 3 times per week or until too intoxicated or impaired to function normally?

Yes No

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

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

Yes No

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

while using, that they would not have done when sober or not under the influence

of drugs or medication?

Yes No

4.  Does it seem as though their mood or behavior deteriorates when they are using drugs,

taking prescription medication or drinking alcohol, or you suspect that they have been?

Yes No
 

5.  Do they seem pre-occupied with, or look forward to drinking, or

taking prescription or illicit drugs throughout the day?

Yes No

 
6.  Have they increased their use to acquire the same feeling or “high”?

Yes No

7.  Have they had to call in sick at work because they were

feeling sick after drinking or using drugs?

 Yes No

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

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

 Yes No

9.  Do they find it difficult to stop using or drinking once they’ve started?

Yes No

 
10.  Has their family, work, social, or spiritual life been negatively effected

by the drinking or use of medication or drugs?

Yes No

11.  Have you or someone else they know ever told them that they think

they have a problem with drinking too much or overusing prescription medication

or illicit drugs?

Yes No

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

Yes No

13.  Have they ever promised you or someone else that “This is the last time”?

Yes No

14.  Did they fail to keep this promise?

Yes No

 
15.  Do they justify their drinking with “I’m stressed” or “I can’t sleep”

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

Yes No

16.  Have they ever said they felt suicidal or that they wanted to hurt themselves

or someone else while drinking, using or because of using or drinking? 

Yes No

 
17.  Have they told you or someone else that they sometimes feel as though

they want to stop or reduce their alcohol or drug use

and then don’t seem to be able to?

Yes No

18.  Has your alcohol or drug use increased as a result of your relationship

with your friend or loved one?

  Yes No

19.  Are you feeling moody, angry or sad, or withdrawing from your relationships

or activities with other people because of the behavior of your friend or loved one?

  Yes No

20.  Does it seem as though they feel as if they have lost hope in

being able to live the full, productive and happy life they want or used to have?

Yes No

21.  Do you feel that you sometimes want to end your relationship with them

or remove them from your life if they continue to use alcohol or

drugs as they are now?

 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.