Addiction Test TestQuestions DemographicInformation YourResults CAGE-AID Questionnaire When thinking about your addiction issues including alcohol, drug use (include illegal drug use and the use of prescription drug use other than prescribed) or other addiction. Have you ever felt that you ought to cut down on your drinking or drug use?*YesNoHave people annoyed you by criticizing your drinking or drug use?*YesNoHave you ever felt bad or guilty about your drinking or drug use?*YesNoHave you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?*YesNoWhat substance or addiction are you concerned about? Alcohol Marijuana Cocaine/Crack Heroin Prescription Opioids Stimulants (e.g. Speed, Meth, Prescription Stims) Benzodiazepines (e.g. Xanax, Valium) Tobacco Cutting Other (e.g. gambling, sex, internet, shopping, food, etc.) Other Substance Please take a moment to answer the following optional questions. Your answers are totally anonymous—we won't be able to identify you based on this information. Your answers help us provide better information and support for people like you. You can answer as many or as few questions as you would like. When you are done, scroll to the bottom of the survey and click "submit" to receive your screening results.About YouAge Range11-1718-2425-3435-4445-5455-6465+GenderMaleFemaleAnother GenderEnter GenderPlease check this box if you identify as transgender. Please check this box if you identify as transgender. Race/EthnicityAsian or Pacific IslanderBlack or African-American (non-Hispanic)Hispanic or LatinoNative American or American IndianWhite (non-Hispanic)More than one of the aboveOtherHousehold IncomeLess than $20,000$20,000 - $39,999$40,000 - $59,999$60,000 - $79,999$80,000 - $99,999$100,000 - $149,999$150,000+Which of the following populations describes you? Veteran or active duty military Caregiver of someone living with emotional or physical illness LGBTQ+ Student Trauma survivor New or expecting mother Healthcare worker Who are you caring for? My spouse or partner My parent My child Another relative Other Caring For - OtherAs a caregiver, what supports do you need? The person I'm helping is getting treatment but is getting worse (meds or therapy stopped working) The person I'm helping is getting treatment but also needs something else (side effects cause other problems, not sure what else to do) The person I'm helping is getting treatment but also needs something else (side effects cause other problems, not sure what else to do) The person I'm helping doesn't want treatment and I want to figure out how to help them I need help because the stress of caretaking is hard Other Caregiver Support - OtherWhich of the following best describes your sexual orientation? Lesbian Gay Bisexual Queer Pansexual Asexual Other Sexual Orientation - OtherAbout Your Mental HealthHave you ever been diagnosed with a mental health condition by a professional (doctor, therapist, etc.)?YesNoHave you ever received treatment/support for a mental health problem?YesNoAre you receiving treatment/support now?YesNoThink about your mental health test. What are the main things contributing to your mental health problems right now?Choose up to 3. Coronavirus Racism Relationship problems Past trauma Current events (news, politics, etc.) Loneliness or isolation Grief or loss of someone or something Financial problems Other… Mental Health Problems - OtherAbout Your HealthDo you currently have health insurance?YesNoDo you have any of the following general health conditions? Heart disease Diabetes Cancer Arthritis or other chronic pain COPD or other lung conditions Movement Disorders (involuntary tics, tardive dyskinesia) HIV/AIDS Other If 'Other' please specify (for general health conditions)Additional InformationStateI live outside the United StatesAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingI live in a U.S. TerritoryZip/Postal CodeWhat country do you live in?AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsPhoneThis field is for validation purposes and should be left unchanged.
