Narconon Australia Drug Treatment and Rehabilitation: Contact us

Contact Narconon Sydney

For more information
v ia E-mail, please enter
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Postal Enquiries:
Admissions
Narconon Sydney
161 Popran Road
Lower Mangrove, N.S.W. 2250
0243771107
narcononsyd@ezweb.com.au

Last Name:

First Name:

M.I.

Address:

City:

State/Province:

Zip/Postal Code:

Country:

Telephone Number:

Email Address:

Is this inquiry for yourself ? yes no

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

Last Name:

First Name:

M.I.

Nickname:

What is this person's relationship to you ?

Please check which drug(s) are involved in the problem:

Alcohol	Designer Drugs	Hypnotics	Methamphetamine	Other Tobacco
Barbituates	Ecstacy	Inhalants	Methadone	PCP
Cigarettes	GHB	Ketamine	Other Amphetamines	Sedatives
Cocaine	Hashish	LSD	Other Hallucinogens	Tranquillizers
Crack	Heroin	Marijuana	Other Opiates

What is the age of the person ?

How long has he/she been using alcohol/drugs ?

How were the drug(s) introduced into the body ?

Intravenous

Smoking

Snorting

Pills

Has the person ever been in treatment before ? yes no

If so, when and where ?

Was it a private program or a state-funded program ? private state-funded

Was it a traditional 12-step program or another type ? 12-step other

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 drug was it ?

How long did they take it ?

Does the person have any known medical conditions ? yes no

If yes, please describe them:

Does the person have any alcohol/drug-related legal situations ? yes no

If yes, please describe them:

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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