Narconon International Help Line

Drug rehab assessment.
If you or someone you know is addicted to drugs or alcohol, one of our Narconon treatment centers can help.
For immediate assistance you can call (877) 947-5900
or complete the online assessment form below and one of our counselors will contact you shortly.

Contact Information:

Last Name:

First Name:

M.I.

Address:

City:

State:

Zip Code:

Country:

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):


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