1.
Have you ever taken -
Drugs
Yes
No
Alcohol
Yes
No
Tobacco
Yes
No
2.
Are you still taking -
Drugs
Yes
No
Alcohol
Yes
No
Tobacco
Yes
No
3.
Do your friends take drugs, alcohol or use tobacco?
Yes
No
4.
Are you worried that you are drinking, taking drugs or smoking too much?
Yes
No
5.
Have you been in any trouble (i.e at school, work or at home) because you have been drinking or taking drugs?
Yes
No
6.
Has a relative or friend been concerned about your drinking or drug taking or suggested that you cut down?
Yes
No
7.
Have you in the last year failed to do what was normally expected of you because of drinking or drug taking?
Yes
No
8.
Have you in the last year been unable to remember what has happened the night before because of drinking or drug taking?
Yes
No
If you have answered YES to any of these questions and think you would like to talk to someone about it, please fill in the
online referral form
. This information will be kept confidentially.
Barbican House,
5 Barbican Close
Barnstaple
EX32 9HE
Tel - 01271 388162
Tel - 01271 325500
info@ysmart.org.uk
