Assessment Form

Are you looking for an effective solution to your drug addiction problem? Look no further!

Please enter your name (required):
Please enter your telephone number:
Please enter your full mailing address:

Please enter your E-mail address (required):
Please enter how long you have been using alcohol/drugs?
Please enter your medical history, treatments, medical condition (HBP, diabetes, heart or kidney problems, etc):

Please enter your age:
Please select the type of drug in which you are involved:
Please select the mental disorder you have been diagnosed with:

Quit drug immediately

Note: Please order first before sending the assessment form. Your password to access the Drug Detoxification Program (exercise, sauna, vitamins/minerals, understanding) eBook will be included in my consultation reply to your assessment.

I will be available for counselling one on one or by phone (unless it is absolutely necessary and depending on individual basis) at 1-604-987-1797 after the initial consultation. Thanks.

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