Narconon Johannesburg Addiction Assessment

Please fill out and submit the form below to start an Addiction Assessment. Or call +27 (0) 11 024 5464 or +27 (0) 11 024 7715 or +27 (0) 84 474 1785 or +27 (0) 72 586 8687 from 8am to 11pm 7 days a week to speak with an admissions counselor about an Addiction Assessment.

* Indicates response required

First Name:*
Last Name:*
Address:
City:
Province or State:
Postal code or Zip:
Day Phone Number:*
Evening Phone Number:*
Email address:*
Is this inquiry for yourself?	Yes     No
If not, enter the name of the person you are concerned about:	Last Name First Name
What is the addict's relationship to you?	Husband Wife Father Mother Son Daughter Grandparent Brother Sister Friend Other
How were the drug(s) introduced into the body?	Intravenous   Smoking    Snorting        Pills
What is the age of the addict?	Less than 18 18-25 26-35 36-45 46-55 56-65 Over 65
Briefly describe the drug history of the addict:
What problems has addiction caused the addict?
What problems has addiction caused the family?
What kind of help do you think the addict needs?
What is the worst problem addiction has caused the addict?
Other Information:
Please describe briefly what is going on with this person right now. Please add any other info you think we should know (i.e. best time to call)
* Would you like to receive more information on addiction?	Yes   No
Please insert the code into the text box below: