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SUBSTANCE USE DISORDER SCREENING

Worried you or a loved one might be struggling with substance use?
Take our quick 5-minute screening to better understand your next steps.

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Substance Use Disorder Screening

Name *

Phone *

Email Address *

How often does alcohol or drug use occur? *Never or rarelyOnce or twice a monthWeeklySeveral times a weekDaily

When substance use happens, how much is typically consumed? *Very little (1-2 drinks or minimal drug use)Moderate amount (3-4 drinks)Large amount (5-6 drinks or significant drug use)Very large amount (7+ drinks or heavy drug use)Excessive amount (binge drinking/drug use)

Is there a desire or attempts to cut down that haven't worked? *No desire to cut downThought about it but haven't triedTried once unsuccessfullyTried multiple times unsuccessfullyConstantly trying but can't stop

How often does substance use interfere with responsibilities (work, school, family)? *NeverRarelySometimesOftenAll the time

How do others react to the substance use? *No one has expressed concernOne person has mentioned itA few people have expressed concernMany people are worriedPeople have given ultimatums or distanced themselves

Are there physical warning signs? (hangovers, blackouts, withdrawal symptoms, using in the morning) *None of theseOccasional hangovers onlyFrequent hangovers or occasional blackoutsRegular blackouts or withdrawal symptomsMultiple symptoms including morning use

Has substance use caused any serious problems? (injuries, legal issues, job loss, relationship damage) *No serious problemsOne minor incidentA few concerning incidentsSeveral serious problemsMultiple severe consequences

How much time is spent thinking about, obtaining, using, or recovering from substances? *Very little to noneOccasionallySome time each weekSignificant time regularlyMost of the day

Has substance use continued despite knowing it causes problems? *No problems causedStopped when problems appearedContinued despite minor problemsContinued despite serious problemsCan't stop despite severe consequences

What's the overall impact on life and relationships? *No negative impactMinor impact, easily managedNoticeable problems in some areasMajor problems in multiple areasLife is falling apart because of substance use

Consent *

Consent to a confidential follow up after analyzing your screening results.

Please do not fill in this field.

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