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UPA/UPM Assessment

Your answers are confidential, will be shredded after you have been assigned to a class, cannot be used to charge additional violations, and will not be kept in your court file. Completion of this questionnaire is voluntary, but if you choose not to complete the questionnaire the judge will not have sufficient information to assign you to a class. She may then need to refer you for a substance use evaluation at your expense.

Be sure to answer the questions honestly. If the judge has reason to question the results of your substance use screen (e.g., inconsistent with other information concerning your case), she may require you to get a substance use evaluation by a certified counselor. Evaluations cost $200 and up.
1. Personal information *This question is required.
Gender
2. Has a relative, friend, doctor or other health care worker been concerned about your drinking or suggested you cut down? *This question is required.
3. Have you or someone else been injured because of your drinking? *This question is required.
4. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? *This question is required.
5. How often during the last year have you found that you were not able to stop drinking once you had started? *This question is required.
6. How often during the last year have you had a feeling a guilt or remorse after drinking? *This question is required.
7. How often during the last year have you been unable to remember what happened the night before because you had been drinking? *This question is required.
8. How often during the last year have you failed to do what was normally expected of you because of drinking? *This question is required.
9. How often do you have a drink containing alcohol? *This question is required.
10. How many standard drinks do you have on a typical day when you are drinking? *This question is required.
11. Male: How often do you have 5 or more standard drinks on one occasion?
Female: How often do you have 4 or more standard drinks on one occasion? *This question is required.
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