Survey – Change with Serenity

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Find out if this program is a good fit for you

Before you begin, please complete this short survey. It helps us make sure this program is the right fit for you.

If eligible, you will recieve a link to purchase the course and may begin immediately.

Survey

First Name

Last Name

Email

Where do you live?

Are you 21 or older?

Yes, I’m 21+

No, under 21

How often do you have a drink containing alcohol? When thinking about alcohol use, include any beer, wine, hard alcohol, etc.

Never

Monthly or less

2-4 times a month

2-4 times a week

4 or more times a week

How many drinks containing alcohol do you have on a typical day when you are drinking? [A standard drink is: 12 ounces of regular beer (which is usually about 5% alcohol), 5 ounces of wine (typically about 12% alcohol), or 1.5 ounces of distilled spirits (about 40% alcohol)]

1 or 2

3 or 4

5 or 6

7 to 9

10 or more

How often do you have six or more drinks on one occasion? [A standard drink is: 12 ounces of regular beer (which is usually about 5% alcohol), 5 ounces of wine (typically about 12% alcohol), or 1.5 ounces of distilled spirits (about 40% alcohol)]

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often in the last year have you found that you were not able to stop drinking once you had started?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often in the last year have you failed to do what was normally expected of you because of drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often in the last year have you needed a drink at the beginning of your day to get yourself going after a heavy drinking session?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often in the last year have you had a feeling of guilt or remorse after drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because of your drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Have you or someone else been injured because of your drinking?

No

Yes, but not in the last year

Yes, during the last year

Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

No

Yes, but not in the last year

Yes, during the last year

I have read and agree to the Terms and Conditions and Privacy Policy

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About the Creator

Meet Serenity Silvers, MPS, LPCC, LADC

Serenity is a licensed psychotherapist specializing in addiction counseling and co-occurring mental health disorders. She blends trauma-informed therapy, narrative therapy, and mindful self-compassion to help people heal from past experiences and create a meaningful, values-driven life.

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Your participation in this program is completely confidential.

This course is for educational purposes only and is not a substitute for professional medical advice or treatment. If you are concerned about your health or alcohol use, please consult a qualified healthcare provider.

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