Alcohol and Drug Rehabilitation - Betty Ford Center Programs

Intervention Application

After completing the application, an Intervention 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 Intervention Application.

*Name of person filling out this form:

*Relationship to patient:

E-Mail:

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:

Street Address

City:

State:

Zip:

*Is this an intervention?
Yes
No

If yes, are you working with an interventionist?
Yes
No

If yes, name interventionist:

PATIENT INFORMATION

*Name of patient:

Marital Status:

Number of children ages 6 - 12:

Patient Street Address:

City:

State:

Zip:

*The individual I am concerned about is having a problem with:
Alcohol
Other Drugs:

Has the patient had prior treatment for alcohol or other drugs?
Yes
No

If yes, please specify:

*Has the patient been hospitalized within the past 30 days?
Yes
No

*What physical medical issues does the patient have?

Are you taking prescribed medications?
Yes
No

If yes, please specify:

Has the patient had:

Tuberculosis?
Yes
No

If yes, please explain:

Hepatitis?
Yes
No

If yes, please explain:

Pain Issues?
Yes
No

If yes, please explain:

Does the patient have allergies?
Medications:

Environment:

Food:

Is the patient currently under the care of?
Psychiatrist
Therapist/Counselor
Psychologist
None

In the past year, has the patient:
Thought of suicide
Planned suicide
Attempted suicide
Unknown

Does the patient have any eating disorders?
Anorexia
Bulimia
None

In the past year, has the patient:
Expressed intention to harm another person
Engaged in threatening behavior
Harmed another person
Received a notice for a restraining order

Who will be listed as the Emergency Contact?

Relationship to patient:

Phone Numbers:

Home:

Cell:

Street Address

City:

State:

Zip:

Who will be the gurantor of the account?

Please indicate method of payment:

Payment for Medications:
Prescription medications are an additional charge. If the patient has coverage for medications, please have them bring their pharmacy benefit card and a credit card to cover any co-payments or amounts not covered by the benefit card

Name of Pharmacy Insurance:

ID #

Group Number

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