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Cuestionario

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Home / Cuestionario

Paso 1 de 15

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Fill out the questionnaire and let us know how to contact you. All information provided is confidential.
What are you struggling with today?

On a scale of 1-10 how much has it impacted your ability to function day to day?

HAVE YOU EVER GOTTEN INTO FINANCIAL, LEGAL, OR Relationship DIFFICULTIES DUE TO your struggles?*
- Yes
- No

HAVE YOU EVER LOST TIME FROM WORK BECAUSE OF your struggles?*
- Yes
- No

Do you feel
Sad?
- Yes
- No
Depressed?
- Yes
- No
Anxious?
- Yes
- No

Struggle to fall or stay asleep?
- Yes
- No
Struggle with appetite? Binge or Purge?
- Yes
- No
Struggle with negative thought patterns?
- Yes
- No

Struggle with highs and low/Mood lability?
- Yes
- No
Engage in self-harming behaviors?*
- Yes
- No
Have you ever been to therapy, hospital or treatment?
- Yes
- No

Are you on any medications?
- Yes
- No
Have you ever been diagnosed with a mental health or addiction issue before?
- Yes
- No
Do you engage in substance abusing behaviors?*
- Yes
- No

HAVE YOU EVER SNEAKED OR HIDDEN YOUR Substance use?*
- Yes
- No
ON OCCASION, DO YOU FEEL UNCOMFORTABLE IF ALCOHOL OR YOUR DRUG IS NOT AVAILABLE?*
- Yes
- No
HAVE YOU EVER SWITCHED TO DIFFERENT DRINKS OR DRUGS OR CHANGED YOUR USING PATTERN IN AN EFFORT TO CONTROL OR REDUCE YOUR CONSUMPTION?*
- Yes
- No

HAS ANYONE EVER SUGGESTED YOU QUIT OR CUT BACK ON YOUR DRUG/ALCOHOL USE?*
- Yes
- No
DO YOU CONTINUE DRINKING OR USING WHEN FRIENDS OR FAMILY SUGGEST YOU HAVE HAD ENOUGH?*
- Yes
- No
HAVE YOU EVER FELT GUILTY OR ASHAMED ABOUT YOUR DRINKING OR USING OR WHAT YOU DID WHILE UNDER THE INFLUENCE?*
- Yes
- No

DO YOU USE OR DRINK ALONE?*
- Yes
- No
DO YOU USE OR DRINK MORE THAN USUAL WHEN UNDER PRESSURE, ANGRY, OR DEPRESSED?*
- Yes
- No
ARE YOU ABLE TO DRINK OR USE MORE NOW WITHOUT FEELING IT, COMPARED TO WHEN YOU FIRST STARTED USING?*
- Yes
- No

HAVE YOU LOST INTEREST IN OTHER ACTIVITIES OR NOTICED A DECREASE IN YOUR AMBITION AS A RESULT OF YOUR DRINKING OR USING?*
- Yes
- No
HAVE YOU HAD THE SHAKES OR TREMORS FOLLOWING HEAVY DRINKING OR USING OR NOT USING FOR A PERIOD OF TIME?*
- Yes
- No
DO YOU WANT TO DRINK OR USE AT A PARTICULAR TIME EACH DAY?*
- Yes
- No
DO YOU GO ON AND OFF THE WAGON?*
- Yes
- No

What are some results you hope to gain from treatment?

When is the best time to contact you?

Are you ready to take your life back?
Name
Este campo es un campo de validación y debe quedar sin cambios.

Si se encuentra en una crisis, llame a la Línea Nacional para la Prevención del Suicidio, una línea gratuita de atención las 24 horas al 1-800-273-8255. Si su problema es una emergencia, llame al 911 o vaya a la sala de emergencias más cercana. El Tratamiento Elemental no ofrece servicios de consejería de crisis o de emergencia.

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