NARCONON Bayern e.V. Member of A.B.L.E International (Association for Better Living & Education)  deutsch    english


Drug Rehabilitation
NARCONON
APPLICATION / QUESTIONNAIRE
(also to use for relatives)


Prerequisites: Basically everybody can be accepted, who want`s to live a life without drugs and alcohol through his own motivation and own will and has a honest interest to make use of the help of NARCONON. Basically the applicant should aspire to personal improvement.

Instructions: Please fill out this questionaire as complete as possible. All details regarding your personal situations will be treated confidential and regarding the regulations of the protection of privacy. The more details you give the faster and more effective we can help. We contact you within 24 hours.Therefore it is very important that you leave a telephone number where we can reach you.
(It is necessary to fill out the spaces marked with an asterisk (*)
First name*

Last name*

Street, Number*
ZIP Code*

City*

State

Country

Phone number*

e-mail address*
Sex  female     male

Is this questionare for yourself ?

  yes   no
If no, please fill in the name of the person:
First name    Last name    Sex
f   m
Which relationship has the person to you?
What kind of drugs are concerned?
First Drug:
Second Drug:
Third Drug:
How is the drug being taken?
Eating  Sniffing  Injecting
 Smoking  Drinken

Age?

Start of Drug Consumption?
What was the age of the first changes in behaviour?
What was the change?
Have there been bigger incidents which have contributed to this problem? (e.g. injury, death, abuse)
Detailed description of drug history:
What problems are caused by the drug consumption?
What problems evolved from the drug consumption in the environment (family, friends, acquaintance)

TREATMENT HISTORY

  
Has there been any drug-treatment? yes     no
If yes, when and what kind?
Was it a private program or sponsored by the state? Private     Official
What was the effect of this treatment?

MEDICAL HISTORY

  
Any known diseases?
 yes    no
If yes what kind of diseases
Has there ever been a diagnosis of mental dysfunction?
 yes     no
If yes, please give details:
Was any medicine taken against mental dysfunction?
 yes      no
If yes what kind of and how long taken?
LEGAL HISTORY  
Are there any open legal affairs (pending processes etc.) ?
 yes      no
If yes, what kind of?
FURTHER INFORMATION  
Do you rsp. the affected person have/has the positive desire to get off alcohol/drugs?  yes    no
Are there any circumstances which could prevent any help?
How are you rsp. the affected person right now? Please give details. Add any questions and information we should know (best time for a call etc.)
How did you find us?
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