Narconon Texas Addiction Assessment

*First Name:

*Last Name:

Address:

City:

State:

Zip:

*Day Time Phone:

*Evening Phone:

*E-Mail Address:

Is this inquiry for yourself?
YesNo

If not, enter the name of the person you are concerned about:

First Name:

Last Name:

What is the addicts relationship to you?
Please Select One Husband Wife Father Mother Son Daughter Grandparent Brother Sister Friend Other
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)