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To begin the pre-enrollment process, please fill out this form and a Narconon Consultant will contact you to assist.

Pre-assessment Questionnaire

1. Are you looking for help for:

Yourself,

Someone you know

1a. If for someone you know, what is this person's relation to you:

2. Which, if any, other drug rehab programs have been done:

3. Has there been any counseling received other than for drug or alcohol use? If so, please state what counseling has been received:

4. Briefly describe the drugs used and the history of the addict:

5. Your contact information:

First Name

Last Name

Phone

Address

Zip/Postal code

Country

City

State/Province

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