Inquiry

If you would like to receive more specific information about our possibilities, please fill in the form below and after that, click on the button in the end to send the form to us. We will contact you soon after that.

PLEASE, DON'T FORGET TO LEAVE YOUR CONTACT DETAILS (e-mail address and/or phone number)!

Kindly make sure you fill in your contact details, so one of our people can contact you.

First, last name, contact details (address, phone, email):

Date of birth:

What substance do you use now, in what daily doses?

How long are you using drugs (from the moment of first use)?

Did you ever had an overdose, what were the side effects, what kind of help was given?

Please indicate if you suffer from illnesses to any of the folowing organs:

heart

lungs

liver

digestive system

other

Did you ever have a head injury which caused loss of consciousness? Was it cured? When and how was it cured?

Are you allergic to anything?

Did you ever have an epileptic attack, loss of consciousness? When and which sort?

Did you ever have problems with depression?

Did you ever have illusions of seeing or hearing things under the influence of narcotics (or without)?

If you were treated before, where and how were you treated and what were the results?

What is your motivation to have a sober life?

What addiction do you seek healing from?