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You are contacting Narconon for:
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Drug History

What Is The Primary Drug of Abuse? Cocaine Heroin Methamphetamine Alcohol Marijuana Painkillers Sedatives LSD (Acid) PCP (Angel Dust) GHB (Rave Drug) MDMA (Ecstacy) Ketamine (Rave Drug) Method of Intake? Intraveneous Smoked Snorted Orally Unsure

What Is The Secondary Drug of Abuse? Cocaine Heroin Methamphetamine Alcohol Marijuana Painkillers Sedatives LSD (Acid) PCP (Angel Dust) GHB (Rave Drug) MDMA (Ecstacy) Ketamine (Rave Drug) No Other Drug of Abuse Method of Intake? Intraveneous Smoked Snorted Orally Unsure

At What Age Did The User First Take Drugs?

How Old Is The User Now?

At What Age Did The Drugs Begin To Affect The Users Life?

What Were The Behaviors That Were Exibited At That Time?

Was There A Single Traumatic Event That Contributed To The Users Addiction?

Presently What Are The Resulting Problems of The User's Addiction?

What Is The Family's Attitude Toward The User's Addiction?

Does The User Admit To Having A Problem? Yes No

Treatment History

How Many Times Has This User Been In Treatment for Their Addiction? Never 1-2 3-5 6 or More

How Many of These Involved The 12-Step (AA Model) Approach To Recovery? All Some None

Was The Treatment Center Privately Funded or Subsidised by Public Funds? Private Public Unsure

Was There Any Success With Any Of These Treatment Modalities?

Medical History

Does The User Have Any Known Medical Conditions? Yes No

If So, Please List The Condition And Any Neccessary Details:

Has This Person Ever Been Diagnosed With Any Psychiatric Disorders? Yes No

If So, Was The Person Treated With Psychiatric Medications? Yes No

If So, Please Specify Medications Taken:

Is He / She Currently On Medication for A Psychiatric Disorder? Yes No

If So, Please Specify Medications Taken: