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Do I need Drug Rehab Treatment

1. I drink or use drugs to relieve feelings of stress when I'm under pressure.
   Yes
   No
2. Whenever I have a reason to celebrate—for example, a job promotion, birthday, or anniversary—drinking or using drugs isone of the first things I make a point of doing.
   Yes
   No
3. I sometimes drink or use drugs heavily after a disappointment or rough day.
   Yes
   No
4. I sometimes feel slightly guilty about my drinking or drug use.
   Yes
   No
5. I experience memory blackouts during or after drinking or using drugs.
   Yes
   No
6. When sober, I sometimes regret things I've said or done while intoxicated.
   Yes
   No
7. I've often failed to keep promises about controlling my drinking or drug use.
   Yes
   No
8. I usually drink or use drugs after a confrontation or argument to relieve my uncomfortable feelings.
   Yes
   No
9. I sometimes have a drink or use a drug first thing in the morning to steady my nerves or get rid of a hangover.
   Yes
   No
10. I designate a set time of the day--for instance, anytime after 4:00 in the afternoon--when it’s okay to begin drinking or using drugs.
    Yes
    No
11. I sometimes stay drunk or high from drugs for more than a few days at a time.
    Yes
    No
12. When I start using, I'm in more of a hurry to get my first "fix" than I used to be.
    Yes
    No
13. I pretty much avoid going places where my drinking or drug use is not acceptable.
    Yes
    No
14. Having a drink or using drugs isusually the first things I do when I come home at the end of the day.
    Yes
    No
15. I feel annoyed about comments on my alcohol or drug use.
    Yes
    No
16. I feel guilt or shame about my use of alcohol or other drugs.
    Yes
    No
17. I have been charged for Driving Under the Influence.
    Yes
    No
18. I have experienced other legal problems and/or accidents as a result of my use of alcohol or other drugs.
    Yes
    No
19. I use alcohol or other drugs to build up my self-confidence.
    Yes
    No
20. Alcohol or other drug use is jeopardizing my job or business.
    Yes
    No
21. I have been to a hospital or other institution due to alcohol or other drug use.
    Yes
    No
22. I use alcohol or other drugs when I am alone.
    Yes
    No
23. I socialize primarily with people who drink or use other drugs.
    Yes
    No
24. I use substances at work or during school.
    Yes
    No
25. I use a variety of drugs.
    Yes
    No
26. I am losing friends because of my drug usage.
    Yes
    No
27. I am at risk of losing my job or failing in school.
    Yes
    No
    

Drug Rehab Utah Treatment Centers Referral Request First Name Phone (Home) Last Name Phone (Work) Email Address Phone (Cell) Best Time to Call am. pm. anytime Dependants Age Group choose 12 to 17 18 to 25 26+ Addicted Person self son daughter spouse father mother friend other If other then self please give addicts first and last name Addicts First Name Addicts Last Name Is addict seeking help? Yes No Main Drug of Choice Alcohol Cocaine Marijuana Meth Methadone Ecstasy PCP Speed Heroin LSD XTC Other Type of Treatment drug rehabilitation drug rehab drug treatment alcohol treatment drug addiction treatment drug abuse treatment substance abuse treatment heroin treatment cocaine treatment marijuana treatment crack treatment meth treatment ecstasy treatment addiction treatment other ... City Layton Ogden Orem Provo Salt Lake City Sandy Taylorsville West Jordan West Valley City List any drug rehab or treatment centers the addict has previously attended. Describe the general situation at the present with the addicted person. Discribe addicted person's legal history. (current & past charges or incarceration} Any additional questions or comments Contact me by : Phone Home E-Mail Phone Work Phone Cell To submit this form you must type the following number in the box below