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End Dependence Questionnaire and Contact

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1. Have you ever abused substances while alone?

2. Have friends and/or family members expressed concern about your substance use?

3. Has your substance use been a source of conflict in your marriage or with your boyfriend/girlfriend?

4. Have you lied to friends or family members about the amount and frequency of your substance use?

5. Have you lied to a doctor in order to obtain prescription medications?

6. Has your substance use negatively impacted your performance at work or school?

7. Have you stolen substances, or stolen money or property in order to buy substances?

8. Have you awakened after using substances with no memory about what you did while you were high?

9. Have you used substances in order to wake up in the morning and/or to go to sleep at night?

10. Have you used one substance in order to intensify the high from another substance?

11. Have you used one substance in order to recover from using another substance?

12. Have you used substances as a way of dealing with stress, pressure, and other negative experiences?

13. Have you tried and failed to reduce the amount and/or frequency of your substance use?

14. When you try to stop using, or when you can’t use, do you start to feel sluggish, sick, agitated, or depressed?

15. Do you worry that you might have a substance abuse problem?


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.

Hillcrest Hospital Henryetta offers detox to those who have been struggling with substance abuse.