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Please fill out the following form in order to apply. Should you want to fill out a paper copy, please find the file at the bottom of this page.

Our Admissions Coordinator is available Monday thru Friday, 8:30 am to 4:00 pm to review our admissions requirements and assess your eligibility for our program. Admission requests can be made by individuals, families, physicians, psychiatrists, referral agents and concerned others.

Referral Date

Applicant Middle Name (if applicable)

Applicant Last Name

Address

Phone

Mobile / Alternative Phone Number

Permission to speak with another member of your household? Yes or No.

Permission to leave a message? Yes or No.

Birthday

Personal Health Care Number

Status # (if applicable)

Highest Level of Education Completed

Emergency Contact Name

Relationship

Telephone Number

Alternate Telephone Number

Referral Agent's Name (if not self referred)

Name of Organization (if not self referred)

Address

Telephone Number

Fax Number

Psychiatrist / Family Physician

Agency

Telephone

Fax Number

Authorization for Release of Information: I, hereby permit the exchange of information between the Baldy Hughes Therapeutic Community & Farm staff and: Physician, Psychiatrist, any mental health office, referral agent / case worker, Pharmanet, any friend or family members assisting with the application, Health Records Departments or any other medical staff involved in my care. This consent will ex

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