Narconon uses a specific method designed to get a person out of denial. The Narconon program has had tremendous success in helping friends or family take the right steps to get the drug user in touch with a Narconon counselor.

A drug user rarely asks for help and if you wait for him to do so, it may be too late. If we can establish some communication with the user, whether we call them or they call us, we have a chance of getting the person up to a point where they want help.

Some Narconon counselors have spent months establishing a relationship in talking with a user and getting them to a point where they decided to get off of drugs. Some families who gave up on a loved one, were shocked but relieved to learn that only after a couple of phone calls with a Narconon counselor, the person was ready to come to the Narconon program.

So by providing us with as much information as possible, we can get you in touch with a counselor that is best suited to handle the situation. All information is strictly confidential and used only to help evaluate the situation.

Drug or Alcohol User Information
(If it is someone you know, fill out as much as possible)

User's Name:
Street Address: (Optional)
City:
State/Province:	AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA 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 VI VT WA WI WV WY AB BC MB NB NF NT NS ON PE QC SK YT Postal ZipCode Country
Day Phone:	Area Code Number Ext#
Night Phone:	Area Code Number Ext#
Email Address:
Currently employed?	Yes No
Occupation:
Gender:	Male Female
Age:

Who's opinion does the user respect the most?

What is the relationship with that person?

Has the user 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?

How are drugs ruining the person's life?

What actions have you taken to try to get this person some help?

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:

How much of the drugs are being used and which ones?

Does the user admit to having a problem and is he/she willing to get help?

What is the user's family situation? (i.e. married, single, children, any family or friends who are interested in helping the user?)

Has the user had any psychiatric treatment? Please give specifics.

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.