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