Online Consultation

If drug addiction is affecting you or a loved one don't hesitate to fill in this form. One of our counselors will contact you and give the assistance you need. Or call our toll free number now.

Toll Free: 1-877-782-7409
Fax: 1-819-376-8135
E-mail: info@narconon.ca

7535 Boulvard Parent
Trois-Rivières, Québec, Canada
G9A 5E1

Contact Information:

*indicate required fields
Your First Name: *
Your Last Name: *
Inquiring for yourself: *	Yes No
If no, please tell us the name of the person who you are inquiring about:
(his/her) First Name:
(his/her) Last Name:
Is Addict seeking help:	Yes No
(your) Address:
City:
State or Province:
Zip Postal:
Country:
Telephone: *
Telephone Work:
Telephone Cell:
Best time to call:	AM PM Evening Anytime
Time Zone:	Eastern Pacific Gw/UT
Email: *

Treatment Options

Please describe briefly what is going on with this person right now: *
Additionnal informations that we should know:

Please let us know how you found us:
If you found us via a search engine, which one?
With the help of which keyword?
You must enter the 4 digit security code appearing at right to proceed with form. *	8411