Answer Yes Or No!

Name

Email Address

Phone

Who Is Seeking Treatment Who Is Seeking TreatmentMyselfLoved OneOther

Do you drink when you are stressed? Do you drink when you are stressed?YesNo

Do you drink when you are mad? Do you drink when you are mad?YesNo

Do you drink alone? Do you drink alone?YesNo

Do you skip work to drink? Do you skip work to drink?YesNo

Do you drink before work or school? Do you drink before work or school?YesNo

Do you chug your drinks? Do you chug your drinks?YesNo

Are you honest about your drinking? Are you honest about your drinking?YesNo

Have been arrested because you were drinking? Have been arrested because you were drinking?YesNo

Do you get drunk daily? Do you get drunk daily?YesNo