Dustin Matnick

This field is hidden when viewing the form

This form requires the Gravity Forms Survey Add-On. Important: Delete this tip before you publish the form.

Name(Required)

First Last

Phone(Required)

Email(Required)

1. How often do you find yourself drinking alcohol?(Required)

2. When you drink alcohol, do you tend to drink more than you planned?(Required)

3. Have you ever tried to cut back or stop drinking, but found it difficult?(Required)

4. Do you experience cravings or urges to drink alcohol, even when it’s not an appropriate time?(Required)

5. How does alcohol affect your ability to handle responsibilities?(Required)

6. Have you ever continued drinking even after it led to problems in your relationships or health?(Required)

7. Do you often feel guilty, anxious, or ashamed after drinking?(Required)

8. Has your tolerance for alcohol increased over time (i.e., needing more alcohol to feel the same effect)?(Required)

9. Have you experienced physical symptoms when you haven’t been able to drink, such as shaking, sweating, or nausea?(Required)

10. How does alcohol affect your mood or behavior?(Required)

11. Do you find yourself prioritizing alcohol over other important aspects of your life (e.g., family, work, hobbies)?(Required)

13. Do you drink to cope with stress, sadness, or other negative emotions?(Required)

14. Has your alcohol consumption ever caused issues with your physical health, such as liver problems or memory issues?(Required)

15. When you think about your future, do you worry about how alcohol might impact your life?(Required)

Anything else you'd like to tell us?

CAPTCHA

Program Director