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 drugs?:
Yes
No
Are you preoccupied with thoughts of using drugs?:
Yes
No
Can you stop using drugs on your own?:
Yes
No
Do you use drugs continuously?:
Yes
No
Do you use more than one drug at a time?:
Yes
No
Are using drugs causing problems with your job?:
Yes
No
Have your relationships been negatively affected?:
Yes
No
Do you refuse to go places where you cannot use drugs?:
Yes
No
Do you need to use drugs to have fun socially?:
Yes
No
Do you do things that are illegal to get drugs?:
Yes
No
Do you lie about using drugs?:
Yes
No
Do you use drugs to escape your problems?:
Yes
No
Have you had medical problems from using drugs?:
Yes
No
Has drug use resulted in legal problems?:
Yes
No
Do you worry that friends or family know you use drugs?:
Yes
No
Do you have withdrawal when you cannot get drugs?:
Yes
No
Do you ever crave drugs?:
Yes
No
Do you use drugs 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 1-888-687-7332.
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If you or a loved one is looking for treatment for any type of substance abuse, please call NOW:
888-687-7332 . 480-827-0322 (your call is confidential)
