The program fee for the Back on Track 2 or more administrative suspensions program is $294.
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We encourage you to complete this form as we are always working to improve. The information in the questionnaire is for the sole purpose of program evaluation by the Centre for Addiction and Mental Health (CAMH).
If you have already completed this questionnaire, please go straight to Registration here.

First Letter of your First Name


Birth Month







What is your current age in years? (For example if you are 24 you would select 2 as the first digit and 4 as the second digit.)

First digit



Second digit


What is the highest level of education you've completed?

In your lifetime, how many Criminal Code drinking driving charges have you had?

In your lifetime, how many roadside suspensions have you had?

What is your marital status?




What is your current employment status?








RIASI
For the following questions please answer according to your experiences in the past 12 months unless otherwise indicated.





R1

I smoke or use tobacco products. (12 months)



R2

I have no problem telling a companion that he or she has done something to hurt my feelings.



R3

I often feel so restless I can’t sit still.



R4

When I drink 7 or more drinks, I become aggressive. (12 months)



R5

I like people who are sharp and witty even though they may sometimes hurt other people's feelings. (12 months)



R6

When the alcohol runs out, I leave a party. (12 months)



R7

When I make plans I am almost certain to make them work. (12 months)



R8

I have relatives who have had problems with alcohol or drugs. (ever)



R9

I have been arrested for crimes other than drinking and driving. (ever)



R10

My hand often shakes when I try to do something. (12 months)



R11

I am irritated a great deal more than people are aware of. (12 months)



R12

Since the age of 18, I have been accidentally cut, or cut in a fight, or burned badly enough to leave a scar. (12 months)



R13

A family member was arrested for drinking and driving. (ever)



R14

When I don’t get my own way, I sulk or pout. (12 months)



R15

I slow down when a traffic light turns yellow. (12 months)



R16

I often feel like a powder keg ready to explode. (12 months)



R17

When I have a problem I try to make it go away by drinking. (ever)



R18

I have no trouble sleeping or staying asleep. (12 months)



R19

I sometimes do dangerous or risky things just for fun. (12 months)



R20

I have experienced a major stressful life event in the in the past 12 months.



R21

I feel that I have lived the right kind of life. (ever)



R22

It is easy for me to turn down an unreasonable request from a friend. (12 months)



R23

I have feelings that something bad will happen to me. (12 months)



R24

I feel like I have lost energy. I am fatigued and tired. (12 months)



R25

I often have feelings of nervousness. (12 months)



R26

I often feel sad or blue. (12 months)



R27

A drink or two gives me energy to get started. (ever)



R28

I am probably not capable of slapping someone, even when I lose my temper. (12 months)



R29

When I get beyond a certain point, I don’t stop drinking until all the booze is gone or I pass out. (12 months)



R30

I don’t like to break rules, even if I think they are wrong. (12 months)



R31

I hardly ever drink more than I plan to. (12 months)



R32

I am not interested in surprising or upsetting others by doing something that might shock them. (12 months)



R33

It depresses me that I did not do more for my parents. (12 months)



R34

I like to gamble for money. (12 months)



R35

After 7 or more drinks I feel happier. (ever)



R36

I often acted without thinking as a child.



R37

I was referred for a liver test, or a blood test for liver enzymes. (ever)



R38

Since the age of the 18, I have needed emergency treatment for an injury of some kind. (ever)



R39

I skipped school as a child. (12 months)



R40

When I am drinking, I make sure I do not skip any meals. (12 months)



R41

I often feel hopeless about the future. (12 months)



R42

In the past five years, how many jobs have you had?



R43

How many traffic tickets for moving violations have you ever received (e.g. speeding, running a red light or stop sign)?



R44

How much money do you usually spend on alcohol per week? Include the cost of drinking at home or at friends’ or relatives’’ houses, and in bars and restaurants and any other places. (12 months)



R45

If you go out drinking, how many places do you drink at in one evening? Include friends’ or relatives’ homes, as well as bars and restaurants and any other places (12 months)



R46

What is the largest number of drinks you ever consumed in a 24 hour period? (one drink = a 12 ounce beer, or a 1 ½ ounce shot of liquor, or a mixed drink, or a 5 ounce glass of wine or a 12 ounce wine cooler.)



R47

How many days of the week do you usually drink? (If you drink less than once a week put in a 0.) (12 months)



R48

When you are drinking, how many drinks do you usually have? (If you never drink, put in a 0.) (12 months)



R49

How many drinks does it take before you begin to feel the effects of alcohol?



R50

I am always courteous even to people who are disagreeable.



R51

I sometimes feel resentful when I don't get my way.



R52

No matter who I'm talking to, I'm always a good listener.








End of questions. Please review the form to be sure that all questions have been answered. Thank you.

To skip this questionnaire, click on the following link:
Continue with Registration for Administrative Suspensions