Screening Test
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Email *
Section 1:
Please enter your name (this is just for us to know that you completed the screening test): *
1.) What types of substances have you or are you currently using? (Check all that apply) *
Use daily/Often
Occasional Use
Past Use
Tried but not Using
Never Used
Tobacco
Vaping Products
Marijuana
Medications not prescribed to you
Alcohol
Other drugs
2.) Do you feel that you may have a problem with vaping, tobacco, alcohol, marijuana or other drugs? *
3.) Has a friend or family member suggested that you may have a problem with vaping, tobacco, alcohol, marijuana or other drugs? *
4.) Have you tried to cut down or quit drinking/using alcohol or cut down or quit smoking/using tobacco, marijuana, or other drugs? *
5.) Have you gone to anyone for help because of your drinking, vaping, tobacco, marijuana or other drug use? *
6.) Has drinking, vaping, tobacco, marijuana or other drug use caused problems between you and your family or friends? *
7.) Has your drinking, vaping, tobacco, marijuana, or other drug use caused problems at school or work? *
8.) Have you had any health problems or injuries as a result of using alcohol, vaping, tobacco, marijuana, or other drugs? *
9.) Have you been arrested or had other legal problems? *
10.) Do you spend a lot of time thinking about or trying to get vaping products, tobacco, marijuana, alcohol or other drugs? *
11.) When drinking, vaping/smoking, using marijuana or other drugs, are you more likely to do something you wouldn't normally do, such as break rules, break the law, lose your temper, sell things that are important to you, or make other unhealthy choices? *
12.) Have any of your family members ever had a drinking or drug problem? *
Section 2:
13. Do you feel that you have excellent or good health? *
14.) Have you ever experienced anxiety, depression, or another emotional or mental health problem? *
15.) Have you ever talked to a psychiatrist, psychologist, therapist, social worker or counselor about a mental health or emotional problem? *
16.) Have you ever felt you needed help with you mental health or emotional problems, or have you had people tell you that you should get help for them? *
17.) Have you ever been seen in an emergency room or been hospitalized for mental health reasons? *
18.) Please answer the following: *
Yes
No
a. Have you ever been depressed for weeks at a time, lost interest or pleasure in most activities, or had trouble concentrating and making decisions?
b. Have you ever thought about harming yourself or others or considered killing yourself?
c. Did you ever attempt to kill yourself?
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