This Assessment is NO substitute for a more thorough assessment by a qualified addiction professional or drug rehab provider.

Please answer the questions to the best of your ability.

1. Have you ever seen your loved one use drugs for reasons other than medical purposes?

 Yes  No  Not Sure

2. When using prescription drugs, does your loved one take more than the indicated dosage recommendations, or require abnormally frequent refills of medications?

 Yes  No  Not Sure

3. Does your loved one often need money and you are not sure for what purposes?

 Yes  No  Not Sure

4. Have you ever found drugs and/or paraphernalia related to drug use in your home?

 Yes  No  Not Sure

5. Have you witnessed a radical change in your loved one’s behavior and appearance that you feel is related to drug use?

 Yes  No  Not Sure

6. Have you noticed a change in friends, interests, and activities in your loved one that has you concerned?

 Yes  No  Not Sure

7. Have you criticized or gotten into arguments with your loved ones about their use/abuse of drugs?

 Yes  No  Not Sure

8. Has your loved one ever been arrested for reasons related to drugs?

 Yes  No  Not Sure

9. Have you ever had to make excuses for work or school to cover up your loved ones’ drug use/abuse?

 Yes  No  Not Sure

10. Has your loved one had medical complications as a result of drug use/abuse?

 Yes  No  Not Sure