As a result of your chemical dependency from drugs and alcohol, have you or a loved one experienced one or more of the following:

1.   Feel it is necessary to drink or use on a daily basis.

2.   Suffer from paranoia, nervousness, cravings or tremors when
  you are not using or drinking.

3.   Experienced financial difficulty.

4.   Suffer from short or long term memory loss.

5.   Suffer from body aches, numbness, severe headaches or
insomnia.

6.   Seem to isolate from family, co-workers or friends.

7.   Display anger, irritability, anxiousness or aggressive behavior more than usual.

8.   Your employment has been affected – excessive tardiness or days off.

9.   Display on-going loss of appetite or severe weight loss.

10. On (1 or more occasions), have you attempted to stop using drugs and/or alcohol and have failed.