Treatment Options Quiz Step 1 of 5 20% CompanyThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formForm TitleSubstance Use1. Do you feel like you can control your substance use? (Yes or No)(Required) Yes No 2. How often do you use drugs or alcohol?(Required) Almost never (once a month or less) A few times a month A few times a week Daily or almost daily 3. Have you tried to quit or cut back on your own? (Yes or No)(Required) Yes No Daily Life Impact4. Has your substance use affected your work, school, or relationships?(Required) No, everything is fine A few issues, but nothing major It’s caused serious problems in my life I’ve lost a job, school, or relationships because of it 5. Have you done risky things while under the influence (driving, unsafe sex, fights)?(Required) Yes No 6. Have you had legal trouble because of drugs or alcohol?(Required) No, never Just a small issue, like a ticket I’ve been arrested or had legal trouble I’ve had multiple arrests or ongoing legal problems Health & Mental Well-being7. Do you feel physically sick when you don’t use?(Required) Yes No 8. Has substance use affected your physical health?(Required) No, I’m healthy I’ve had minor issues like hangovers or feeling run down I’ve had repeated health problems because of it I’ve been hospitalized or have serious health issues Health & Mental Well-being9. Do you have a mental health condition like anxiety, depression, or PTSD?(Required) Yes No 10. Do you have a strong support system of family or friends to help you?(Required) Yes, I have great support Some support, but not always consistent My support system is weak or unreliable I don’t have support, or I’m around people who use Name(Required) First Last Phone(Required)Email(Required)
