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79 Glenridge Rd. Glenville, NY 12302

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Health Screening

Screening Tool

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.

Alcohol

How often did you have a drink containing alcohol, even beer or wine, in the past year?




How many drinks do you have on a typical day when you drink?




How often did you have 5 (for men) 4 (women) or more drinks on one occasion in the past year?




Has anyone else ever thought you might have a problem with alcohol?


Have you or someone else ever been injured as a result of your drinking?


Have you ever experienced negative consequences due to your use, that effected any of the following areas; Legal, financial, family, employment, physical health?


Prescription Medication Misuse

Have you ever taken prescription medication that was not prescribed for you?


Have you ever taken prescription medication in a way that was not prescribed?


Have you ever taken prescription medication only for the feeling or experience that it caused?


Have you ever experienced negative consequences due to your use, that effected any of the following areas; Legal, financial, family, employment, physical health?


Drugs

Have you ever used drugs such as marijuana, heroin, cocaine, PCP, LSD, methamphetamine, ecstasy?


Have you ever used any drugs by injection?


Have you ever experienced negative consequences due to your use, that effected any of the following areas; Legal, financial, family, employment, physical health?


** Based on your responses to the questions above, a + screen to any of the above questions may indicate the need for a more comprehensive assessment to help determine if you or someone you care about may have a Alcohol, Prescription or Drug abuse problem. Please feel free to contact our nearest Outpatient location to schedule an evaluation. All information is confidential and protected by HIPAA and Federal confidentiality laws
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79 Glenridge Road Glenville,
NY 12302

Phone: (800) 989-6446
Fax: (518) 691-9317
(518) 691-9211

Conifer Park is licensed by the Joint Commission, who ensures quality of care and safe practices and also by the New York State Office of Alcoholism and Substance Abuse Services (OASAS).
Conifer Park is proud to be employee owned (ESOP).

COPYRIGHT © 2021 · CONIFER PARK · POWER BY EMBER. ACCESSIBILITY