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Family Program Registration

After completing the application, a Family Counselor or Family Program Registrar will contact you within 72 hours to answer any questions and continue the process.  

Click here for a printable version of the Family Program Registration.


  
Date:
E-Mail:
Last Name:
First Name:
Street Address

City:

State:

Zip:
 Phone Numbers
Home:

Work:

Cell:
DOB:
 Age:
Occupation:
Marital Status:
Gender

 Referred By
Name:

Phone Number:

E-mail:
Do you have someone in treatment?

Is the patient at Betty Ford Center?
If no, name of other facility:
  
Name of Patient:
 Relationship to Patient:
Date of Family Attendance:
(usually the third week of patient’s treatment)
 
Have you ever been to any BFC Programs? (Required)

  

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