Please complete the following form and click Submit. We will contact you as soon as possible regarding the results. Your information is confidential and will only be seen by the River Source staff.
Fields marked * are required.
Email Address: *
Phone Number:
Are you unhappy with the way your life is going?:
Yes
No
Do you feel you may have a problem with alcohol?:
Yes
No
Are you preoccupied with thoughts of drinking?:
Yes
No
Can you stop drinking after one glass?:
Yes
No
Do you drink alone?:
Yes
No
Is drinking affecting your reputation?:
Yes
No
Is drinking causing problems with your job?:
Yes
No
Have your relationships been negatively affected?:
Yes
No
Do you refuse to go places where you cannot drink?:
Yes
No
Do you need to drink to have fun socially?:
Yes
No
Is drinking causing you financial difficulties?:
Yes
No
Do you hide alcohol from family or friends?:
Yes
No
Do you lie about your drinking?:
Yes
No
Do you drink to escape your problems?:
Yes
No
Do you drink to overcome shyness with other people?:
Yes
No
Has alcohol resulted in legal problems (DUI/DWI)?:
Yes
No
Do you worry that friends or family know you drink?:
Yes
No
Do you have memory loss from drinking?:
Yes
No
Do you ever crave alcohol?:
Yes
No
Do you drink to cope with fear or anger or depression?:
Yes
No
Are you willing and able to get treatment at The River Source?:
Yes
No
If yes please submit this form and contact us now at .
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If you or a loved one is looking for treatment for any type of substance abuse, please call NOW:
