SBIRT - Screening Brief Intervention and Referral to Treatment Program

The Sixth Judicial District SBIRT
Self-Report 3 Question Screen Form

First Name:    

Last Name:    

Date of Birth:

Read questions as written. Record answers carefully.  Examples of what is meant by "alcoholic beverages" are beer, wine, vodka, etc.  Answer the questions in terms of "standard drinks".  The answer number values will automatic code by the form.

  1. How often do you have a drink containing alcohol?
    Never
    Monthly or less
    2 to 4 times a month
    2 to 3 times a week
    4 or more times a week
  2. How many drinks containing alcohol do you have on a typical day when you are drinking?
    1 or 2
    3 or 4
    5 or 6
    7 to 9
    10 or more
  3. How often do you have five or more drinks on one occasion?
    Never
    Less than monthly
    Monthly
    Weekly
    Daily or almost daily

    4. Current Score: 0

    Scoring
        ≥ 3       ≥ 4
    Women     Men
    		  =  Positive

    If positive, go to AUDIT, you have at least RISKY alcohol use.