Free Web Site - Free Web Space and Site Hosting - Web Hosting - Internet Store and Ecommerce Solution Provider - High Speed Internet
Search the Web

Assessment

 

Home
Assessment
Groups/Educators
Photo Album
Resources

 

This page was last updated on 02/16/06.

 

Copyright © 2004 by me. All rights reserved. NARCONON, the FIRST STEP PROGRAM and the Narconon Logo are registered trademarks and service marks owned by the Association for Better Living and Education, and are used with its permission.

  If you need assistance in locating a drug rehab and drug addiction treatment centers near you, use the form below and call us at (262) 637-6860.

  Call us for help in locating drug rehabilitation and drug addiction treatment centers in near you.

 
Drug FactYour Name:
Drug FactEmail :
Drug FactDay Phone #:
Drug FactEvening Phone #:
Drug FactAddress:
Drug FactCity: Drug FactState:
Drug FactPostal Code:

Drug FactPerson you wish to help ? self other 
      If other, who are you concerned about: 

   Name:  Relationship:

Drug FactHow old is the addict ? 

Drug FactDoes the addict want help ? yes no

Drug FactPlease list drugs abused: 
 

Drug FactPrimary:
Drug FactSecond:
Drug FactThird:

Drug FactHow does the addict obtain drugs/alcohol ? 

Works  Steals  Prescription  Deals  Other

Drug FactCan the addict travel? 
yes no 
 

Drug FactPlease describe any personal / family problems the addict has.

Drug FactPlease describe any legal problems the addict has.

Drug FactPlease describe the overall behavior & condition of the addict.

Drug FactIs there any diagnosed medical condition? (Please describe)

Drug FactIs there any diagnosed mental disorder? (Please describe)

Drug FactDid the addict on any medication for any of the above? 
yes no 
 

  Medication?  How long? 

Drug FactHas the person ever attempted to stop using drugs before ?
yes no 

     If so, by which method?
 

Self  12-step  Non-Hospital Residential  Hospital  Other

Drug FactIf the addict has received treatment, please describe? (Include name of the facility, 12-step, etc.)

Drug FactWas it a private program or a state-funded program ? 
private state-funded 

Was there any success with the prior treatment ? (How long did the addict stay clean, etc?)

Drug FactIs there anything else you would like us to know?