TREATMENT INTAKE APPLICATION

A Few Things To Keep In Mind:

All new Clients must bring with them a TENNESSEE DRIVER’S LICENSE OR TENNESSEE STATE ID.

Any potential Clients that are taking prescribed medication(s) need to have arrangements made so that they arrive with a 90 Day Supply of their medication(s).

 

You’re almost there! The intake application is below. Please be sure to include your full name (or full name of potential Client) and take your time to make sure you provide all the information you can; this will help us to help you. 

Also, please note that after you fill out the application, allow 24-48 hours & GIVE US A CALL.

 Please be honest. We are here to help you recover.

 

Intake Application

Please First Select Your Method of Payment

We work with Tennesseeans who do not have inusrance. We are fortunate to provide treatment service to male individuals living in Tennessee.

Radio buttons

 

Name: Client first name Client last name

Gender:

 Radio buttons

 

Date of Birth:

Date

 

Do You Have a Social Security Card?

 Radio buttons

 

SSN:

Text field

 

Address: Client Address Client City Client State Client Zip

 

Primary Contact Number: Client phone

Secondary Contact Number: Client phone

 

Have You Ever Been a Client of TRC before?

Radio buttons

 

Substance(s) of Use:

Client substances of choice

When Was The Last Day You Used?

Date

Are You an I.V. User?

Radio buttons

 

If You Have Felonies, Pleast List Them Here Honestly: Text field

 

Are You Currently On Probation?

Radio buttons

If You Are On Probation, What Is Your Probation Officer's Name? Text field

County of Probation: Text field

Probation Officer's Phone Number: Client phone

Probation Officer's Email: Client email

Probation Officer's Fax: Client phone

 

Do You Have An Attorney?

Radio buttons

If You Have An Attorney, What Is Their Name? Text field

Attorney's Phone Number: Client phone

If Possible, Attorney's E-Mail Client email

 

Are You a Violent Offender?

Radio buttons

Are You a Sex Offender?

Radio buttons

 

Do You Have a VALID Tennessee Driver's License or Tennessee State ID?

Radio buttons

License or ID #: Text field

 

Do You Have a Current Mental Health Diagnosis?

Radio buttons

If Yes: Client diagnosis

 

 

Are You Currently Taking Any Medications?

If Yes: Medication

Do You Have Any Health Problems?

If Yes: Client health problems

 

Do You Have Any Allergies?

Client allergies

 

Do You Have a Disability?

Radio buttons

If Yes: Text field

 

Is Your Family Supportive?

Radio buttons

 

May We Mention TRC If We Need To Call You?

Radio buttons

 

Is There Any Information You Can Provide To Assist Us In Your Consideration For Admission?

Paragraph

 

How Did You Hear About Tony Rice Center? Text field

 

I agree that the information I have provided to Tony Rice Center is accurate & honest. I am ready for a change, and I am willing to be honest and open-minded.

Signature

Please Remember: Once You Submit, Allow 24 Hours & GIVE US A CALL!

For Intake & Admissions: (931) 492-4206

For All Other TRC

Questions: (931) 685-0957