Online Self Assessment

Aetna Magellan Preferred Provider Blue Cross Preferred Provider

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Online Self Assessment

Please tell us about yourself and answer the following yes/no questions about drug and alcohol use, then press "submit" to send the email to us:

Your Name:
Telephone Number:
Email Address:

Yes No	1. Do you ever look forward to the end of a day’s work so you can have drinks or drugs?
Yes No	2. Do you sometimes look forward to the end of the week so you can have some fun drinking and using?
Yes No	3. Do you find that you can often drink or use more than others and not show it too much?
Yes No	4. Have you noticed that you are able to handle more liquor or drugs than you did when you were first drinking or using?
Yes No	5. Do you often find that you wish to continue drinking or using after your friends say that they have had enough?
Yes No	6. Do you ever take more than the prescribed amount of medication?
Yes No	7. Do you usually have drinks or drugs before going to a party or out to dinner?
Yes No	8. Do you sometimes drink at home alone, or when no one else is drinking?
Yes No	9. Do you ever stop in a bar or club and have a couple of drinks alone?
Yes No	10. Do you sometimes use drugs alone?
Yes No	11. Have you ever been arrested for a DWI or DUI?
Yes No	12. Do you ever drink or use drugs to calm your nerves, reduce tension, or relieve stress?
Yes No	13. Do you find it difficult to enjoy a party or dance if there is nothing to drink or no drugs to take?
Yes No	14. Have you taken a drink in the morning or taken drugs to ease a hangover?
Yes No	15. The morning following an evening of drinking or "drugging," have you ever been unable to remember everything that happened the night before?
Yes No	16. Do you sometimes stash a bottle or drugs around the house in case you may need a drink or drugs sometime?
Yes No	17. Do you sometimes feel a little guilty about your drinking or using?
Yes No	18. Have you ever had the shakes or hand tremors in the morning after?
Yes No	19. Did you ever stop in to have a drink or two and then have several more than you planned?
Yes No	20. Have you ever missed work or school because of a hangover?
Yes No	21. Have you often failed to keep the promises you have made to yourself about controlling or cutting down on your drinking or using?
Yes No	22. Do you eat very little or irregularly when you are drinking or using?
Yes No	23. Do you have a very definite preference to associate with people who drink or use drugs as opposed to those who do not?
Yes No	24. Do you sometimes do things while drinking or using that you are ashamed of later?
Yes No	25. Do you sometimes stay drunk or high for several days at a time?

PLEASE INCLUDE YOUR EMAIL AND PHONE NUMBER.
YOUR INFORMATION WILL BE KEPT CONFIDENTIAL.

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