In the past year, how many have you Once or Never Monthly Weekly used [X]? Twice ☐ ☐ ☐ ☐ Tobacco Products ☐ ☐ ☐ ☐ Alcohol ☐ ☐ ☐ ☐ Marijuana ☐ ☐ ☐ ☐ Illegal Drugs (i.e. cocaine or Ecstasy) Prescription drugs that were not prescribed for ☐ ☐ ☐ ☐ you (i.e. Pain Medication or Adderall) Inhalants (i.e. nitrous ☐ ☐ ☐ ☐ or synthetic drugs (i.e. salvia, K2, or bath ☐ ☐ ☐ ☐ salts) S2BI Algorithm Thank you for answering these questions. Based on what you shared, we would like to connect you to an agency in your local community (near you) for a further assessment and information about services to assist with your needs. How does that sound?
In the past year, how many have you used [X]? Never Once or Twice Monthly Weekly Tobacco Products ☐ ☐ ☐ ☐ Alcohol ☐ ☐ ☐ ☐ Marijuana ☐ ☐ ☐ ☐ Illegal Drugs (i.e. cocaine or Ecstasy) ☐ ☐ ☐ ☐ Prescription drugs that were not prescribed for you (i.e. Pain Medication or Adderall) ☐ ☐ ☐ ☐ Inhalants (i.e. nitrous ☐ ☐ ☐ ☐ or synthetic drugs (i.e. salvia, K2, or bath salts) ☐ ☐ ☐ ☐ S2BI Algorithm Thank you for answering these questions. Based on what you shared, we would like to connect you to an agency in your local community (near you) for a further assessment and information about services to assist with your needs. How does that sound?
ScreeningYouthPAPERVERSION61317.docx