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ADMISSION APPLICATION

This form can be completed by the applicant and/or family member and includes personal, social, health and treatment information.


TREATMENT PROVIDER REFERRAL FORM

This form is to be completed and signed by the current attending outpatient psychiatrist and should include supporting documents such as lab results and psychiatric evaluations. If the applicant is hospitalized, we request full records for the current and all past hospitalizations.


RELEASE OF INFORMATION FORM

We would like to have any past records from hospitals, therapists, psychiatrists, or other information you think would be helpful.

This form should be completed, signed and forwarded directly to the Medical Records Department of EACH hospital or agency that has provided psychiatric treatment for the applicant. It may be helpful to hand write at the top of the form, “Please expedite for the purpose of application to a residential program.” This form should also be forwarded to previous private therapists and psychiatrists who have provided treatment.


FINANCIAL ASSISTANCE APPLICATION

Gould Farm is committed to affordability of residential treatment. Through the generosity of many donors, we extend financial assistance to qualifying families.  To determine eligibility, please complete the Application for Financial Assistance.


You can click on the links in the Admission Forms section above to open and fill out each form. These forms are writable pdf documents that you can fill out electronically and submit to Gould Farm via email or fax. You do not have to fill out any form all in one sitting. Click on the form, save it locally to your device and fill it out. Once form is completed you can email it as an attachment to admissions@gouldfarm.org or fax to 413-645-1022.


At any point in considering Gould Farm as a treatment option, please connect with our Director of Admissions, Tamara McKernan, at 413.528.1804 ext. 32 or admissions@gouldfarm.org.