Addiction Self Assessment

Is This You or Someone You Know?

The use of alcohol and other drugs is a normal part of most cultures, both in ceremony and as part of everyday social interaction. Many people use alcohol and drugs without developing physical or psychological symptoms. Those who abuse substances may also have underlying mental or physical problems. Substance abuse is continued use that has negative consequences but without necessarily losing control over the use.

Substance Dependence

Substance dependence is the loss of control over the use of the substance, which begins to dominate a persons’ life so that their social, work, or psychological functioning is impaired as a result. Dependence can be both physical and psychological. Many people also continue to abuse alcohol and drugs to avoid the symptoms of withdrawal.

Substance Tolerance

Substance tolerance means that increased amounts of the drug are needed to produce the same affect.

Drug and alcohol dependence or addiction

Drug and alcohol dependence or addiction is identified when someone is distressed, has impaired behavior and 3 or more of the following factors are present over a one month period.

  • Tolerance of the substance, defined by either needing more of the substance or resulting in a reduced effect while using the same amount
  • Symptoms of withdrawal or when drugs or alcohol are taken to avoid withdrawal
  • The substance is taken in larger amounts or for longer than is intended
  • There is a desire to cut down or control the intake of the substance
  • A large amount of time is spent on activities associated with acquiring the drug or alcohol, using it, or recovering from its side effects
  • The user withdraws from other activities because of its side effects
  • The user knows they have a physical or psychological problem caused or exacerbated by drug or alcohol addiction but still continues to use

The factors that cause drug or alcohol addiction and dependency are many. Some people have a genetic tendency to addiction. For example, children of alcoholics are four times more likely to develop problems with alcohol abuse even when raised apart from their drinking parents.

Psychological Factors of Addiction

The psychological factors of addiction can include using drugs or alcohol to get high or to help cope with physical or emotional pain such as depression and anxiety, or to avoid conflict. The effects of addiction can include loss of friends and relationship problems, loss of work, being unreliable or unable to work, unemployment, loss of income, neglecting children and legal problems.

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Addiction Self-Assessment

Our brief assessment form is designed to enable you to provide us with an overview of your needs or the needs of the person you are referring to us. Please try to complete all of the information on this form.

Full Name
Email Address
Telephone Number (incl. codes)
Age
Gender
Location
How long have you been using substances?
How frequently do you use substances?
Referral Type
Proposed Program Date
Proposed Program Duration
Are you currently taking any prescribed medication?
Any other comments