Substance Questionnaire

This form is intended as a tool for students to evaluate concerns that they may have about themselves or a friend with regards to substance abuse.  We encourage our students to fill out this form and then talk to their guidance counselor, a teacher, or one of the building principals.

HOW CAN I TELL IF MY FRIEND OR I HAVE A SUBSTANCE ABUSE PROBLEM?

1) Do you or your friend ever lose time from school due to drinking alcohol or using drugs.

             

Y or N

2) Do you or your friend use drugs to feel more comfortable, forget about worries or studies, or to build self-confidence?      

    

Y or N

3) Do you or your friend use substance alone?    

                                                       

Y or N

4) Do you or your friend ever feel guilty because of substance use?     

                                

Y or N

5) Have you or your friend ever gotten in trouble at home or school for substance use?      

            

Y or N

6) Do you or your friend do without other things or borrow money in order to get the substance?    

 

Y or N

7) Do you or your friend feel a sense of power when using substances?        

                           

Y or N

8) Have you or your friend lost friends since beginning to use the substance?        

                   

Y or N

9) Have you or your friend started hanging out with a heavy substance abusing crowd?

 

Y or N

10) Do you or your friend use the substance until it is all gone?               

                        

Y or N

11) Does your friend turn off studies or lectures about substance use?     

                             

Y or N