V-CARE | Pre-Assessment & Registration

Nickname / Alias * Age (Optional) Gender (Optional) Preferred Assessment Date *

1. Used tobacco products (including vape)

Yes No

2. Used alcohol

Yes No

3. Used sedatives or sleeping pills

Yes No

4. Used stimulants (cocaine, methamphetamine)

Yes No

5. Used hallucinogens (LSD, mushrooms)

Yes No

6. Used opioids (heroin, painkillers)

Yes No

7. Used inhalants (glue, gasoline)

Yes No

8. Ever injected drugs

Yes No

9. Experienced problems due to substance use

Yes No

10. Tried almost every type of drug

Yes No

11. Drug use is out of control

Yes No

12. Trouble controlling alcohol use

Yes No

13. Heard voices others could not hear

Yes No

14. Seen things others could not see

Yes No

15. Others can read my thoughts

Yes No

VDAAP