First Name *

Last Name

Email *

Do you think your drinking is out of control? *

Always/Nearly Always

Often

Sometimes

Never/Almost Never

Does the prospect of not drinking make you feel anxious or worried? *

Always/Nearly Always

Often

Sometimes

Never/Almost Never

Do you worry about your drinking?

Always/Nearly Always

Often

Sometimes

Never/Almost Never

Do you wish you could stop drinking alcohol?

Always/Nearly Always

Often

Sometimes

Never/Almost Never

If you've tried to stop drinking in the past, how difficult did you find going without alcohol?

Impossible

Very Difficult

Quite Difficult

Not Difficult

NEXT