Please complete this questionnaire honestly. We can than contact you with further advice on steps you can take. Contact Details: Name: Email: Telephone:   Do you drink/take drugs to relieve stress? Never Occasionally Often Always   Do you drink/take drugs alone? Never Occasionally Often Always   Is drinking/taking drugs making your home life unhappy? Never Occasionally Often Always   Do you drink/take drugs to feel more self confident? Never Occasionally Often Always   In the past year have you tried to stop drinking/taking drugs? Never Occasionally Often Always   Have you missed work in the last year due to a hangover/drinking/taking drugs? Never Occasionally Often Always   Is drinking/taking drugs affecting your job or business? Never Occasionally Often Always   Are you afraid of meeting people first thing in the morning? Never Occasionally Often Always   Have you been in financial difficulties because of your drinking/taking drugs? Never Occasionally Often Always   Have you seen your doctor because of your drinking/taking drugs? Never Occasionally Often Always   If you have any other information you wish to let us know, please type in the box below and then submit your questionnaire.