Are you worried about yourself or a loved one?^*

1. Do you often use drugs or alcohol in larger amounts or over a longer period of time than you intended?^*

2. Have you for a while now wanted to cut back on drugs or alcohol or made unsuccessful attempts to do so?^*

3. Do you spend a great deal of time finding, using, or recovering from drugs or alcohol?^*

4. Do you have strong urges or powerful cravings to use drugs or alcohol?^*

5. Has your use of drugs or alcohol resulted in your inability to meet your obligations at work, home, or school?^*

6. Have you had to cut back on or abandon social, professional, or recreational activities due to your use of drugs or alcohol?^*

7. Have you repeatedly used drugs or alcohol when it was hazardous to do so, such as while driving a car or operating machinery?^*

8. Have you experienced social or relationship problems due to your use of drugs or alcohol and kept using anyway?^*

9. Have you kept using drugs or alcohol knowing that it has caused or worsened physical or mental health issues?^*

10. When you attempt to cut back on or stop your use of drugs or alcohol, have you experienced uncomfortable physical or mental health symptoms (withdrawal)?^*

11. Have you experienced diminished effects when you use drugs or alcohol compared to the past and/or have you needed more drugs or alcohol in order to feel the effects you're seeking (tolerance)?^*

Do you have any other comments, questions, or concerns?

Your Full Name^*

Your email Id^*

Your Contact No.^*