James Fitzgerald Therapy, PLLC James Fitzgerald, MS, NCC, AAP, Psychotherapist Strengthening Your Conscious Self © 2022 Client Intake: Assessments Alcohol and Drug Use Brief Survey Please enable JavaScript in your browser to complete this form.Annual QuestionnaireOnce a year, all my clients are asked to complete this form because drug and alcohol use can affect your physical health which affects your mental health as well as medications you may take. Please help me provide you with the best clinical care by answering the questions below. LayoutUser ID (number)DateAre you currently active in a recovery fellowship?YesNoAre you concerned about your alcohol or drug use?YesNoIs someone else concerned about your alcohol or drug use?YesNoHow much alcohol is in a standard drink? MEN: How many times in the past year have you had 5 or more drinks in a day?NoneOne or moreWOMEN: How many times in the past year have you had 4 or more drinks in a day?NoneOne or moreDRUGSRecreational drugs include methamphetamines (speed, crystal), cannabis (marijuana, pot), inhalants (paint thinner, aerosol, glue), tranquilizers (Valium), barbiturates, cocaine, ecstasy, hallucinogens (LSD, mushrooms), or narcotics (heroin). How many times in the past year have you used a recreational drug or used a prescription medication for nonmedical reasons? NoneOne or moreSubmitSave and Resume Later Your form entry has been saved and a unique link has been created which you can access to resume this form. Enter your email address to receive the link via email. Alternatively, you can copy and save the link below. Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted. Copy Link Email * Send Link