Self-Assessment Tool – 4D Recovery

First Name

Last Name

Phone/Mobile

Age Range

Under 18

18 or Older

This confidential self-assessment is designed to help you reflect on your alcohol and drug use and identify whether additional support may be helpful. The assessment is not a diagnosis and is intended for educational and referral purposes only.

If you are under 18: You should still complete the assessment. Your responses will help us connect you with youth-appropriate recovery support services.

Have you used drugs other than those required for medical reasons?

Yes

Do you abuse more than one drug at a time?

Yes

Are you always able to stop using drugs when you want to?

Yes

Have you had blackouts or flashbacks as a result of drug use?

Yes

Do you ever feel bad or guilty about your drug use?

Yes

Does a parent, guardian, family member, partner, or friend ever complain about your drug use?

Yes

Have you neglected responsibilities at home, school, work, or with family because of drug use?

Yes

Have you engaged in illegal activities to obtain drugs?

Yes

Have you experienced withdrawal symptoms when you stopped using drugs?

Yes

Have you had medical problems as a result of drug use?

Yes

Do you feel you are a normal drinker?

Yes

Have you ever awakened after drinking and been unable to remember part of the evening before?

Yes

Does a parent, guardian, family member, partner, or friend ever worry or complain about your drinking?

Yes

Can you stop drinking without difficulty after one or two drinks?

Yes

Do you ever feel guilty about your drinking?

Yes

Have you ever attended a recovery meeting because of your drinking?

Yes

Have you ever gotten into a physical fight when drinking?

Yes

Has drinking ever created problems between you and family members, friends, or significant others?

Yes

Have you ever gotten into trouble at school, work, or with the law because of drinking?

Yes

Have you ever sought help for your drinking?

Yes

Self Assessment Tool