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The document is an admission form for the South Country Treatment Centre, outlining the requirements and procedures for clients seeking treatment for addictions. It includes sections for personal identification, health and legal information, referral details, financial arrangements, and a checklist of items and conditions necessary for admission. The centre emphasizes that it is a non-medical facility and requires clients to resolve any medical or legal issues prior to admission.

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Click ‘Get Form’ to open the admission form in the editor.
Begin by filling out your identification information. Enter your first name, last name, address, and contact details accurately. Ensure that your email address is correct for communication purposes.
Proceed to Part II and provide referral information if applicable. Include the name of the referral agency and any previous treatment details.
In Part III, disclose any health, medical, or legal issues. Be thorough in listing medications and health concerns as this is crucial for your treatment eligibility.
Complete Part IV regarding your alcohol/drug and gambling history. This section helps the center understand your background better.
Finally, review all sections for accuracy before submitting. Confirm that you have signed where required and understand the terms outlined in the consent form.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Is Hazelden a 12-step program?

Hazelden was established in 1949, with a forward-thinking approach to the problem of alcoholisman approach built on emerging Twelve Step principles and practices, lay counseling and abiding compassion for the individual receiving care.

How much does Hazelden Betty Ford cost?

Some outpatient programs, such as the program at Hazelden Betty Ford, cost $10,000. The price tag depends on how often the individual visits the center each week and for how long.

Did Eric Clapton go to Hazelden?

After calling his manager and admitting he was an alcoholic, Clapton flew to MinneapolisSaint Paul in January 1982 and checked in at Hazelden Treatment Center, located in Center City, Minnesota.

Who is Hazelden Betty Ford?

Hazelden Betty Ford is a mission-driven, community-oriented behavioral healthcare organization. From the very start, charitable support and a commitment to innovation have driven Hazelden Betty Fords advances in treatment, research, educational programs and services in order to reach and help more people.

Did Hazelden buy Betty Ford?

The Betty Ford Center board endorsed the merger Tuesday. Hazelden voted for it last week. The deal ensures: The Hazelden Betty Ford Foundation, with 14 sites nationwide, will be run by Mark Mishek, Hazeldens president and chief executive officer.