Step 1/9
Have you ever abused substances while alone?
Yes
No
Have friends and/or family members expressed concern about your substance use?
Yes
No
Step 2/9
Has your substance use been a source of conflict in your marriage or with your boyfriend/girlfriend?
Yes
No
Have you lied to a doctor in order to obtain prescription medications?
Yes
No
Step 3/9
Has your substance use negatively impacted your performance at work or school?
Yes
No
Have you stolen substances, or stolen money or property in order to buy substances?
Yes
No
Step 4/9
Have you awakened after using substances with no memory about what you did while you were high?
Yes
No
Have you used one substance in order to intensify the high from another substance?
Yes
No
Step 5/9
Have you used substances as a way of dealing with stress, pressure, and other negative experiences?
Yes
No
Have you tried and failed to reduce the amount and/or frequency of your substance use?
Yes
No
Step 6/9
When you try to stop using, or when you can’t use, do you start to feel sluggish, sick, agitated, or depressed?
Yes
No
Have you lied to friends or family members about the amount and frequency of your substance use?
Yes
No
Step 7/9
Have you used substances in order to wake up in the morning and/or to go to sleep at night?
Yes
No
Have you used one substance in order to recover from using another substance?
Yes
No
Step 8/9
Do you worry that you might have a substance abuse problem?
Yes
No
Step 9/9
Email Address
"How did you hear about First Responders First? "
TV
Radio
Newspaper
"Your Relationship To Person Needing Treatment "
Parents
Cousin
Brother
Back
Next step
Your form has been submitted successfully!
Oops! Something went wrong while submitting the form.