Message of the day

Nothing inspires honesty like fear or trouble. - Steve Maraboli
~...

Self-assessment questionnaire form

Fill this out to get your Free 15-min consult
  • This questionnaire will help to evaluate your current situation. You may use this form to assess yourself or discuss the answers with a dependency coach.

    Completing an honest assessment to evaluate your situation is the first step in any recovery process.
  •   Yes
      No
  •   Depression
      Anxiety
      OCD
      Mood Disorder
      Sustance Abuse
      Alcohol Abuse
      Not applicable
  •   Very serious
      Moderately serious
      Concerned
      I'm looking for more info
  •   Yes
      No
  •   Quit completely
      Quit completely over a period of time
      Moderate drinking
      Harm reduction strategy
      Other
  •   Yes
      No
  •   Yes
      No
  •   Yes
      No
  •   Morning
      Afternoon
      Evening
      Weekends
      Weeknights
      Anytime
  •   12-step program (AA)
      Therapy
      Consulted with a medical doctor
      Willpower on your own
      Other
      None-I haven't tried