HEROIN

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CONTACT INFORMATION

We understand and respect confidentiality!

For a completely obligation free assessment of your situation as well as pricing and payment information, give us a call toll-free at 1-877-413-3073 or, for best service, submit your information using the profile form below.

Your Name: Email : Phone #:       Home    Work    Cell   Fax                          Address: City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Postal Code: Person you wish to help ?   self   other       If other, who are you concerned about:      Name: Relationship: husband wife father mother son daughter grandparent friend other How old is the addict ? less than 18 18 - 25 26 - 35 36 - 45 46 - 55 56 - 65 over 65 Does the addict want help ?   yes   no Please list drugs abused:      Primary:   Alcohol Cocaine Crack Heroin Methamphetamine Ecstasy GHB Inhalants Ketamine LSD Marijuana Methadone PCP Prescription Drugs Other Second:   Alcohol Cocaine Crack Heroin Methamphetamine Ecstasy GHB Inhalants Ketamine LSD Marijuana Methadone PCP Prescription Drugs Other Third:   Alcohol Cocaine Crack Heroin Methamphetamine Ecstasy GHB Inhalants Ketamine LSD Marijuana Methadone PCP Prescription Drugs Other How does the addict obtain drugs/alcohol ?          Works     Steals     Prescription     Deals     Other Please describe any personal / family problems the addict has.       Please describe any legal problems the addict has.       Please describe the overall behavior & condition of the addict.       Is there any diagnosed medical condition? (Please describe)       Is there any diagnosed mental disorder? (Please describe)       Did the addict on any medication for any of the above?   yes   no      Medication? How long ? Has the person ever attempted to stop using drugs before ?   yes   no      If so, by which method?        Self     12-step     Non-Hospital Residential     Hospital     Other If the addict has received treatment, please describe? (Include name of the facility, 12-step, etc.)        Was it a private program or a state-funded program ?   private   state-funded Was there any success with the prior treatment ? (How long did the addict stay clean, etc?)       Is there anything else you would like us to know?

PROGRAM DESCRIPTIONlllllllSUCCESS STORIESlllllll AWARDS & CREDENTIALSlllllllFAQlllllllHOMElllllll © 2002 Narconon of Georgia, Inc. All Rights Reserved. NARCONON and the Narconon logo are trademarks and service marks owned by Association for Better Living and Education International and are used with its permission.

PROGRAM DESCRIPTIONlllllllSUCCESS STORIESlllllllAWARDS & CREDENTIALSlllllllFAQ

© 2002 Narconon of Georgia, Inc. All Rights Reserved. NARCONON and the Narconon logo are trademarks and service marks owned by Association for Better Living and Education International and are used with its permission.