Narconon® Contact by Narconon Arrowhead & narcononcenter.com

Welcome to narcononcenter.com

on-line consultation

You may also call 1-800-468-6933 from 8am to 11pm 7 days a week to speak with an admissions counselor.

Contact Information:

»Last Name:

»First Name:

»M.I.

»Address:

»City:

»State:

»Zip Code:

»Country:

»Daytime Phone:

»Evening Phone:

»Email :

»Is this inquiry for yourself ? yes no

If not, please enter the name of the person you are concerned about:

Last Name:

First Name:

M.I.

»What is this addicts's relationship to you ?

Drug History:

»Please indicate which drug(s) are involved in the problem:

Drug of Choice:	Second Choice:	Third Choice:

»How were the drug(s) introduced into the body ?

Intravenous

Smoking

Snorting

Pills

»What is the age of the addict ?

»When did the addict start using drugs ?

»At what age did the addict exhibit behavior changes ?

»What were the changes ?

»Are there any major events contributing to this problem ?
(For example: trauma, death, abuse, etc.)

»Briefly describe the drug history of the addict.

»What problems has addiction caused the addict?

»What problems has addiction caused the family?

Treatment History:

»Has the person ever undergone addiction treatment ? yes no

If so, when and where ?

»Was it a private program or a state-funded program ?
private state-funded

»Was it a traditional 12-step program or another type ? 12-step other

»What effect did this treatment have ?

Medical History:

»Does the person have any known medical conditions ? yes no

If yes, please describe them:

»Has the person ever been diagnosed with a mental disorder ? yes no

If yes, please specify:

»Did he/she receive medication for the disorder ? yes no

If yes, what ?

How long was it taken ?

Legal History:

»Does the person have any alcohol/drug-related legal situations ? yes no

If yes, please describe them:

Other Information:

»Does the addict express the desire to get off drugs/alcohol ? yes no

»What is the higest level of education completed by the addict ?

»Is there anything that would prevent the addict from receiving help ?

»Please describe briefly what is going on with this person right now.
Also add any other information that we should know (best time to call, etc):

»Would you like to receive more information on addiction yes no

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