DUAL DIAGNOSIS SCREEN FOR ADULTS

Name (optional):______________________________

Questions to Screen for Alcohol and/or Other Drug Problems

1. Are your friends, family or others concerned about your use of alcohol and/or drugs?           * Yes * No  If yes, who/how/when:_____________________________________________
2. Have you tried to stop or cut down on your drinking and/or drug use? * Yes * No If yes, how/when:________________________________________________________________
3. Have you been in any trouble or neglected your responsibilities because of your use of alcohol and/or drugs? * Yes * No If yes, how/when:_______________________________

_________________________________________________________________________

4. Do you have problems with work, school, family, law enforcement or others due to your use of alcohol or other drugs? * Yes * No If yes, who/how/when: ________________________

_________________________________________________________________________

5. Do you feel you have a problem with alcohol or drugs? * Yes * No If yes, how/when: _________________________________________________________________________

Questions to Screen for Mental Health Problems

6. Have you experienced sadness/depression, nervousness, worry, mood changes or disturbing thoughts? * Yes * No If yes, how/when:________________________________

_________________________________________________________________________

7. Have you had any thoughts, plans or attempts to harm yourself, others or property? * Yes * No If yes, how/when:_________________________________________________

[if yes, must connect individual with counselor or clinician immediately upon completion of screening tool]

8. Have you received professional help or medication for an emotional problem? * Yes * No If yes, how/when:__________________________________________________________
9. Are your friends, family or others concerned about your emotional well-being? * Yes * No If yes, how/when: ___________________________________________________________
10. Are you concerned about your safety? * Yes * No If yes, how/when:__________________

___________________________________________________________________

• [If there is a YES response to questions 7, 10 or both, immediately connect with  a clinician or  call the Access and Crisis Line at 1-800-439-3339.