Penfield Call Request

While the best way to begin the admission process is to call us at (706) 453-7929, you can submit some basic information to get the process started by completing the form below.

Your Name * First Last
Please provide us with your name. If you are filling out this form for someone else, please provide their name below.
I Am Filling Out This Form For (If Needed) First Last
If you are filling out this form for someone else, please provide their name here.
Your Primary Email Address *

All of your information, including your email address, is secure and will remain private! We will never share, sell, or lend your email address to anyone!
Best Number To Reach You - (###) - ### ####
Home, Cell or Work Phone Number
Alternate Number To Reach You (If Needed) - (###) - ### ####
Home, Cell or Work Phone Number
Best Time To Reach You 9-12Noon 12-1PM 1-4PM ASAP
Primary Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Your address or if you are filling out this form for someone else, please provide their address here.
Have You Been A Client at Penfield Before? Yes No Not Sure
If you are filling out this form for someone else, have they been a client at Penfield before?
If Yes, Can You Provide The Approximate Date? / MM / DD YYYY
If you are filling out this form for someone else, and they have been a client at Penfield before, please provide the approximate date they were previously at Penfield here.
How Did You Hear About Penfield?
If you have completed all of the above, that will give us enough to reach you and begin the screening process. If possible, please continue with the rest of the questions in respect to the person applying for admission to Penfield Christian Homes.
Date Of Birth / MM / DD YYYY
Social Security Number
***** Emergency Contact #1 *****
Emergency Contact #1 Name First Last
Emergency Contact #1 Relationship To Applicant
Emergency Contact #1 Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Emergency Contact #1 Primary Number - (###) - ### ####
Emergency Contact #1 Alternate Number - (###) - ### ####
Emergency Contact #1 Primary Email

All of your information, including your email address, is secure and will remain private! We will never share, sell, or lend your email address to anyone!
***** Emergency Contact #2 *****
Emergency Contact #2 Name First Last
Emergency Contact #2 Relationship To Applicant
Emergency Contact #2 Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Emergency Contact #2 Primary Number - (###) - ### ####
Emergency Contact #2 Alternate Number - (###) - ### ####
Emergency Contact #2 Primary Email

All of your information, including your email address, is secure and will remain private! We will never share, sell, or lend your email address to anyone!
***** Medical Information *****
Current Physician's Name Title First Last Suffix
Applicant's Current Physician (If Any)
Current Physician's Office Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Current Physician's Office Address (If Known)
Current Physician's Office Phone - (###) - ### ####
Current Physician's Office Number (If Known)
Current Physician's Office Fax - (###) - ### ####
Current Physician's Office Fax Number (If Known)
Current Medications

Please list all current medications and and dosages of each medication. If applicant is not currently taking any medications, please complete this box with "NONE"
Any Allergies to Medications, Foods, or Environmental Factors
What Has Caused You To Seek Help At This Point In Your Life?
Any Addition Information For Us

If you have additional information or comments you would like to add, you can do so here. (ie - A brief history of the applicants drinking or drug use.)

Penfield Call Request

Penfield Call Request

If you have completed all of the above, that will give us enough to reach you and begin the screening process. If possible, please continue with the rest of the questions in respect to the person applying for admission to Penfield Christian Homes.

***** Emergency Contact #1 *****

***** Emergency Contact #2 *****

***** Medical Information *****

* Emergency Contact #1 *

* Emergency Contact #2 *

* Medical Information *