Alcohol and Drug Rehabilitation - Betty Ford Center Programs

Betty Ford Center Admissions Application

After completing the application, an Admissions Counselor will contact you within 24 hours to answer any questions and continue the process. Completing this form is not a guarantee or obligation for treatment. *Indicates required field.

Click here for a printable version of the Admissions Application.

PATIENT INFORMATION
*Name of person filling out this form:	*Relationship to patient:
*E-mail Address:
Street Address: City: State: Zip:	Phone Numbers: (Only list the numbers that you can be contacted on) If you would like to contact us instead, do not leave your phone numbers. Please contact our Admissions Department: (800) 854-9211. Home: Cell:
*Is this an intervention? Yes No	If yes, are you working with an interventionist? Yes No
If yes, name interventionist:
*Name of patient:	Marital Status:
Number of children ages 6 - 12:
Patient Street Address: City: State: Zip:	I am having a problem with: Alcohol Other Drugs:
Have you had prior treatment for alcohol or other drugs? Yes No	If yes, please specify:
*Have you been hospitalized within the past 30 days? Yes No
Are you taking prescribed medications? Yes No	If yes, please specify:
Are you currently under the care of? Psychiatrist Therapist/Counselor Psychologist None	Who will be the gurantor of the account?
Please indicate method of payment:

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May 12 - May 16
Family Professionals in Residence
May 15 - May 18
California Children's Program
May 17
Growing Your Spirituality in Recover
May 17
Santa Barbara Alumni Chapter Luncheo

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