Get Drug Rehab Help from Narconon of Georgia

Please fill out the information below and we will refer you to a Narconon program that best meets your needs. If you need immediate help, call (toll free) 1-877-413-3073.

Your Name:
Email :
Phone #:       
Home    Work    Cell   Fax                         
Address:
City: State: Postal Code:
How did you find our Website? Internet? Which search engine? Email? Other?

Person you wish to help ?   self   other

      If other, who are you concerned about:
  Name: Relationship:

How old is the addict ?

Does the addict want help ?   yes   no

Please list drugs abused:
     Primary:
  		Second:
  		Third:
 

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?
     



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