Have you used any substances other than those PRESCRIBED BY YOUR DOCTOR? *

Yes
No

Do you use more than one substance at a time? *

Yes
No

Do you have difficulty stopping use of substances when you want to? *

Yes
No

Have you had "blackouts" or "flashbacks" as a result of substance use? *

Yes
No

Do you ever feel bad or guilty about your substance use? *

Yes
No

Do family or friends ever complain about your use of substances? *

Yes
No

Have you neglected your family because of your use of substances? *

Yes
No

Have you engaged in illegal activities while on substances or in order to obtain substances? (driving intoxicated, theft, etc)? *

Yes
No

Have you ever experienced withdrawal symptoms (felt physically ill, shakes, depression, increased anxiety, sleep problems, etc.) when you stopped using substances? *

Yes
No

Have you had medical problems as a result of your substance use (e.g., memory loss, elevated enzymes, hepatitis, convulsions, bleeding, etc.)? *

Yes
No

Substance Abuse Evaluation Results:

You scored X points out of 10.

Based on your responses, you have a low likelihood of substance abuse. If you are concerned, call 855-306-8054 to speak with an addiction treatment professional now. Addiction is progressive and can worsen over time, so early intervention is important.Based on your responses, you have a moderate level of substance abuse and may need inpatient or outpatient treatment for a potential substance use disorder. Call 855-306-8054 to speak with an addiction treatment professional now.

Request a call and confidentially check your rehab insurance coverage (optional)

First Name *

Last Name *

Best Callback Number *

Insurance Name

Insurance Member ID

Date of birth

Street

City

State

Zip Code

(felt use? Campaign

Free, Confidential Substance Use Assessment

Substance Abuse Evaluation Results:

Request a call and confidentially check your rehab insurance coverage (optional)