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Voluntary
Out-Patient
Withdrawal

Contact Narconon Edmonton

Please fill out the following confidential form to have a Narconon Edmonton representative contact you.

Reason for contact:

Name:

E-Mail address:

Phone (Home):

Phone (Work):

Phone (Cell):

Best time to call:

Province/State:

Addict's Name:

Drug of choice 1:

Drug of choice 2:

Is Addict seeking help :

List any Drug rehab program previously attended and if Treatment was completed

Describe any medication history, past or present(Name, Length, dosage, etc.)

Describe addicted person's history (hospitalizations, psychiatric evaluations, present illnesses, etc.)

Describe addicted person's legal history (current & past charges or incarceration)

Comments/Questions