Call Us Today
785-825-6224
Forms
Addiction
Alcohol
Cannabis
Hallucinogens
Inhalants
Opioids
Phencyclidine
Sedative, Hypnotic, Anxiolytic
Stimulants
Tobacco
Addiction Self-Assessment
Treatment Services
CKF Telehealth Addiction Treatment
Pathfinder Recovery Center
Anger Management
Batterers’ Intervention Program
Education Classes
Family Support
Medication Assisted Treatment
Mental Health
Outpatient
Prevention & Education
Residential
Social Detoxification
Medical Integration Services
Medical Referrals
Services in Medical Settings
Staff Training
Contracting
Provider Portal
Locations
About
CKF in the News
FAQs & Resources
Our Mission & Purpose
Our Story
Meet Our Team
Privacy & Safety
Terms & Conditions
News
Careers
Give
Contact
Addiction
Alcohol
Cannabis
Hallucinogens
Inhalants
Opioids
Phencyclidine
Sedative, Hypnotic, Anxiolytic
Stimulants
Tobacco
Addiction Self-Assessment
Treatment Services
CKF Telehealth Addiction Treatment
Pathfinder Recovery Center
Anger Management
Batterers’ Intervention Program
Education Classes
Family Support
Medication Assisted Treatment
Mental Health
Outpatient
Prevention & Education
Residential
Social Detoxification
Medical Integration Services
Medical Referrals
Services in Medical Settings
Staff Training
Contracting
Provider Portal
Locations
About
CKF in the News
FAQs & Resources
Our Mission & Purpose
Our Story
Meet Our Team
Privacy & Safety
Terms & Conditions
News
Careers
Give
Contact
Help | Hope | Healing
Addiction Self-Assessment
Contact Us
24 Hours A Day
Date
Date Format: MM slash DD slash YYYY
Your Name
*
Your Email
*
Message Subject
*
Your Message
Phone
This field is for validation purposes and should be left unchanged.
Have you used prescription drugs at higher doses than recommended or needed to obtain a new prescription before the due date?
Yes
No
Have you had "blackouts" or "flashbacks" as a result of substances (including alcohol) use?
Yes
No
Have you been arrested for possession of illegal substances (including alcohol)?
Yes
No
Have you engaged in illegal activities in order to obtain substances (including alcohol)?
Yes
No
Have you lost a job because of substance use (including alcohol)?
Yes
No
Have you neglected your family because of your use of substances (including alcohol)?
Yes
No
Are you unable to stop using substances (including alcohol) when you want to?
Yes
No
Have you been in trouble at work because of substance use (including alcohol)?
Yes
No
Has substance use (including alcohol) created problems between you and your spouse or your parents?
Yes
No
Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking substances (including alcohol)?
Yes
No
Does your spouse (or parents) ever complain about your involvement with substances (including alcohol)?
Yes
No
Have you gone to anyone for help for a substance problem (including alcohol)?
Yes
No
Do you use more than one substance at a time (including alcohol)?
Yes
No
Have you had medical problems as a result of your substance use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?
Yes
No
Have you gotten into fights when under the influence of substances (including alcohol)?
Yes
No
Have you been involved in a treatment program specifically related to substance use (including alcohol)?
Yes
No
Have you used substances (including alcohol) other than those required for medicinal reasons?
Yes
No
Are you unable to get through the week without using substances (including alcohol)?
Yes
No
Have you lost friends because of your use of substances (including alcohol)?
Yes
No
Do you ever feel bad or guilty about your substance (including alcohol) use?
Yes
No
Addiction
Alcohol
Cannabis
Hallucinogens
Inhalants
Opioids
Phencyclidine
Sedative, Hypnotic, Anxiolytic
Stimulants
Tobacco
Addiction Self-Assessment
Treatment Services
CKF Telehealth Addiction Treatment
Pathfinder Recovery Center
Anger Management
Batterers’ Intervention Program
Education Classes
Family Support
Medication Assisted Treatment
Mental Health
Outpatient
Prevention & Education
Residential
Social Detoxification
Medical Integration Services
Medical Referrals
Services in Medical Settings
Staff Training
Contracting
Provider Portal
Locations
About
CKF in the News
FAQs & Resources
Our Mission & Purpose
Our Story
Meet Our Team
Privacy & Safety
Terms & Conditions
News
Careers
Give
Contact