The Narconon program has had great success in working with people who have a drug or alcohol problem. We are here to help you and any information you provide is kept strictly confidential.

1. Pick up the phone and call our hotline if you are ready to talk to a counselor now.

2. If you are not ready to talk to someone on the phone right now, then fill out the following information and send it to us immediately.
   

Please Answer the Following Questions

How are drugs ruining your life?

What effects has drug use had on your life? (i.e. family, work, relationships, etc.)

What do you foresee will happen in the future if you don't stop your drug use?

What would your life be like if you changed and got off drugs and/or stopped drinking?

Why do you want to quit?

Have you ever been in other rehab programs? Yes No

If yes, which ones? (Check all that apply) Alcoholics Anonymous Hazeldon Day Top Betty Ford Charter Phoenix House Palmer Drug Abuse The Meadows Other If you selected "Other" above, what is the name of the rehab program?

What were the results?

Have you had any psychiatric treatment? Please give specifics.

What is your family situation? (i.e. married, single, children, any family or friends who want to help you?)

Drug Use: (Please check the types of drugs used.) Marijuana Cocaine Crack Alcohol Heroin Amphetamines Hallucinogens Barbituates Medical Psychotropic Drugs Inhalants Other

If you selected "Other", please explain:

What drugs are you using right now and how much?

Any serious physical problems? If yes, what are they?

If you have a medical emergency you should call 911 right away! If you need to speak to us urgently, call our toll free hotline now... 1-888-774-2345

Otherwise, click on the SUBMIT button below to send this form, so that we can assist you as quickly as possible.