In this section, you will find several questionnaires to help you determine if you have addiction and are in need of treatment. Am I an Alcoholic? Am I An Alcoholic? 1. Have you ever awakened the morning after some drinking the night before and found that you could not remember part of the evening before? Yes No 2. Does your family ever worry or complain about your drinking? Yes No 3. Do friends or relatives think you are a normal drinker? Yes No 4. Are you always able to stop drinking when you want to? Yes No 5. Have you ever attended a meeting of Alcoholics Anonymous (AA)? Yes No 6. Have you gotten into fights when drinking? Yes No 7. Has drinking ever created problems with you and your family? Yes No 8. Has your family ever gone to anyone for help about your drinking? Yes No 9. Have you ever lost friends or relationships because of your drinking? Yes No 10. Have you ever gotten into trouble at work because of your drinking? Yes No 11. Have you ever lost a job because of drinking? Yes No Am I Co-Dependent? Am I Co-Dependent? 1. I often make decision for other but have a terrible time making decisions for myself. Yes No 2. I have difficulty forming and maintaining close relationships and have grown to expect, often from experience, people to leave me. Yes No 3. I tend to attract people with many problems in hopes that I will help to “fix” them and live happily ever after. Yes No 4. I believe I am responsible for other people’s feelings and/or behaviors. Yes No 5. I have difficulty identifying my own feelings; my sense of how i “feel” in response to the feelings and/or behaviors of others. Yes No 6. I tend to be very critical and judgmental of myself and others. Yes No 7. I have difficulty setting goals for myself placing the needs of those around me first. Yes No 8. I have low energy from the “struggle” of living. Yes No 9. I constantly seek approval and affirmation. Yes No 10. I fail to recognize my accomplishments. Yes No 11. I fear criticism. Yes No 12. I overextend myself. Yes No 13. I have problems with my own compulsive behaviors. Yes No 14. I have a need for perfection. Yes No 15. I am uneasy when my life is going smoothly, continually anticipating problems. Yes No 16. I feel more alive in the midst of a crisis. Yes No 17. I care for other people easily, yet find it hard to care for myself. Yes No 18. I isolate from other people. Yes No 19. I respond with fear to authority figures and angry people. Yes No Am I a Cocaine Addict? Am I a Cocaine Addict? 1. Have you ever used more cocaine than you planned? Yes No 2. Has the use of cocaine interfered with your job? Yes No 3. Is your cocaine use causing conflict with your spouse or family? Yes No 4. Do you feel depressed, guilty or remorseful after you use cocaine? Yes No 5. Do you use whatever cocaine you have, almost continually, until the supply is exhausted? Yes No 6. Have you ever experience sinus problems or nosebleeds due to cocaine use? Yes No 7. Do you ever wish you had never taken that first line, hit or injection of cocaine? Yes No 8. Have you experienced chest pains or rapid or irregular heartbeats when using cocaine? Yes No 9. Do you have an obsession to get cocaine when you do not have it? Yes No 10. Are you experiencing financial difficulties due to your cocaine use? Yes No 11. Do you experience an anticipation high just knowing you are about to use cocaine? Yes No 12. After using cocaine, do you have difficulty sleeping without taking a drink or other drug? Yes No 13. Are you absorbed with the thought of getting loaded even while interacting with a friend or loved one? Yes No 14. Have you begun to use drugs alone or drink alone? Yes No 15. Do you ever have feelings that people are talking about you or watching you? Yes No 16. Do you have to use larger amounts of drugs or alcohol to get the same high you once experienced? Yes No 17. Have you tried to quit or cut down on your cocaine use, only to find that you could not? Yes No 18. Have any of your friends or family suggested that you may have a problem? Yes No 19. Have you ever lied to or misled those around you about how much or how often you use? Yes No 20. Are you afraid that if you stop using cocaine or alcohol, your work will suffer or you will lose your energy? Yes No 21. Have you been arrested more than once for driving under the influence of alcohol? Yes No 22. Do you spend time with people or in places you otherwise would not be around, but for the availability of drugs? Yes No 23. Have you ever stolen drugs or money from friends or family? Yes No Am I a Food Addict? Am I a Food Addict? 1. Have you ever wanted to stop eating and found you just couldn’t? Yes No 2. Do you constantly think about food or your weight? Yes No 3. Do you find yourself attempting one diet or food plan after another, with no lasting success? Yes No 4. Do you binge and then “get rid of the binge” through vomiting, exercise, laxatives, or other forms of purging? Yes No 5. Do you eat differently in private than you do in front of other people? Yes No 6. Do you often stuff yourself with a lot of food in a short period of time? Yes No 7. Do you often crave and consume large amounts of high calorie or junk food? Yes No 8. Do you hide food – or hide from others while you’re eating? Yes No 9. Do you eat until someone interrupts you, you feel abdominal pain, you fall asleep or you start vomiting? Yes No 10. Have you ever tried to lose weight by chronic fasting, severely restricted diets, induced vomiting, laxatives or diuretics? Yes No 11. Are you afraid of not being able to stop eating voluntarily or have you not been able to stop eating voluntarily? Yes No 12. Do you frequently experience depression, guilt or harsh thoughts about yourself after an eating binge? Yes No 13. Do you ever eat/ purge/ starve more than you intended to? Yes No 14. Do people criticize your eating/ purging/ starving? Yes No 15. Do you think you become a different person after you have eaten/ purger/ starved? Yes No 16. Do you ever feel guilty about the way you eat/ purge/ starve? Yes No 17. Do you ever sneak food? Yes No Am I a Gambler? Am I a Compulsive Gambler? 1. Do you experience mood swings based on winnings and losses? Yes No 2. Do you neglect other responsibilities in order to concentrate on gambling activities? Yes No 3. Do you experience impatience with loved ones because they are interrupting your gambling activities? Yes No 4. Are you willing to eat less or go without food so that you can gamble? Yes No 5. Do you gamble with money designated for necessary expenses such as household supplies, groceries, medication, electricity and telephone? Yes No 6. Have you ever thought about cashing in your insurance policy for gambling money? Yes No 7. Are you spending your retirement funds to gamble? Yes No 8. Do you fantasize about big winnings and believe you will win back all of your loses? Yes No Am I a Pot Addict? Am I a Pot Addict? 1. Do you ever smoke marijuana for reasons other than fun? Yes No 2. Do you leave parties early, choose not to go out, choose friends based on your marijuana use? Yes No 3. Do you smoke alone? Yes No 4. Do you worry about running out of pot? Yes No 5. Do you get anxious when you can’t get more pot? Yes No 6. Do you avoid dealing with emotions, problems or responsibilities by smoking weed? Yes No 7. Has your use of marijuana caused problems with your memory, concentration, or motivation? Yes No 8. Have you ever tried to cut back or quit smoking pot before and failed? Yes No 9. Have your friends or family expressed concern about your lifestyle or pot use? Yes No 10. Do you ever substitute another substance, like alcohol, when weed is not around? Yes No Please enter your e-mail and a trained clinician will get back to you. If you have any questions or would like to speak to you a trained clinician, call us and ask for our intake department. We will discuss the program with you in detail answering any and all your questions. This phone call is confidential.