You must have JavaScript enabled to use this form. Have you ever abused substances while alone? * Yes No Have friends and/or family members expressed concern about your substance use? * Yes No Has your substance use been a source of conflict in your marriage or with your boyfriend/girlfriend? * Yes No Have you lied to friends or family members about the amount and frequency of your substance use? * Yes No Have you lied to a doctor in order to obtain prescription medications? * Yes No Has your substance use negatively impacted your performance at work or school? * Yes No Have you stolen substances, or stolen money or property in order to buy substances? * Yes No Have you awakened after using substances with no memory about what you did while you were high? * Yes No Have you used substances in order to wake up in the morning and/or to go to sleep at night? * Yes No Have you used one substance in order to intensify the high from another substance? * Yes No Have you used one substance in order to recover from using another substance? * Yes No Have you used substances as a way of dealing with stress, pressure, and other negative experiences? * Yes No Have you tried and failed to reduce the amount and/or frequency of your substance use? * Yes No When you try to stop using, or when you can't use, do you start to feel sluggish, sick, agitated, or depressed? * Yes No Do you worry that you might have a substance abuse problem? * Yes No If you are in a state of crisis or need immediate help for any reason, please call 911. If you feel that you are a danger to yourself, please contact the National Suicide Prevention Lifeline at 1-800-273-8255. If you answered "yes" to any of the questions provided, it is highly recommended that you contact the staff at Hillcrest or another qualified healthcare provider. If you would prefer to be contacted by the staff at Hillcrest we encourage you to leave your contact information in the space provided. Please note that by leaving your information, you consent to allow Hillcrest to use this information to contact you. Any information provided will remain confidential. If you answered "no" to the questions provided, you are still encouraged to reach out to the staff at Hillcrest or another qualified healthcare provider for a detailed evaluation of your risk for Substance Abuse. This online Substance Abuse assessment is strictly for general information purposes and is not a substitute for an in-person clinical evaluation. This assessment is not a formal diagnostic tool and should not be interpreted as such. Your answers will remain anonymous, if you choose. Please note that by choosing to not leave your information, the staff at Hillcrest will not contact you. Disclaimer: Hillcrest disclaims any liability, loss, or risk sustained as a consequence, directly or indirectly, of the use and application of these assessments. First Name * Last Name * Email * Phone * Preferred Location * - Select -Hillcrest HenryettaHillcrest Cushing Problem Substance - check all that apply Alcohol Opioids Methamphetamines Cocaine Other Other Option Comments Hillcrest Hospital Henryetta offers detox to those who have been struggling with substance abuse. Submit
