Contact Narconon Denmark

Call: +45 59 27 91 47 for a free consultation
or fillout the below form

 

Information:

.
First name:
Last name :
Address:
City and zipcode:
Country:
Phone number :
E-mail address:
Is this inquiry for yourself :         Yes     No
If not, please enter the name of the person you are concerned about:
Firstname:       Lastname:
What is this addicts's relationship to you?   .
Please indicate which drug(s) are involved in the problem
  
How were the drug(s) introduced into the body? Intravenous  Smoking  Snorting  Pills
What is the age of the addict?
When did the addict start
using drugs?
At what age did the addict exhibit behavior changes?
What were the changes?
Are there any major events contributing to this problem ?
For example: trauma, death, abuse, etc.).
Briefly describe the drug history of the addict:
What problems has addiction caused the addict:
What problems has addiction caused the family:
Treatment History:
Has the person ever undergone addiction treatment? Yes   No
If so, when and where?
Was it a private program or a state-funded program? Privat   State
Was it a traditional 12-step program or another type? 12 steps Andet
What effect did this treatment have?
Medical History:
Does the person have any known medical conditions? Yes    No
If yes, please describe them:
Has the person ever been diagnosed with a mental disorder?    Yes    No
If yes, please specify:
Did he/she receive medication for the disorder?    Yes     No
If yes, what how long was it taken?
Other Information:
Does the addict express the desire to get off drugs/alcohol   Yes   No
What is the higest level of education completed by the addict ?
Is there anything that would prevent the addict from receiving help?
Beskriv venligst:
Please describe briefly what is going on with this person right now.
Also add any other information that we should know (best time to call, etc):
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