Questions

All information below is confidentail and will not be shared with anyone family/public

Question: C Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or other drugs?

Yes
No

Question: R Do you ever use alcohol or other drugs to RELAX, feel better about yourself, or fit in?

Yes
No

Question: A Do you ever use alcohol or other drugs while you are ALONE?

Yes
No

Question: F Do you ever FORGET things you did while using alcohol or other drugs??

Yes
No

Question: F Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?

Yes
No

Question: T Have you ever gotten into TROUBLE while you were using alcohol or other drugs?

Yes
No

Question: Would you like to be discus any details further and if so what is the best way for us to contact you?

Yes
No

Phone:
Email:


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