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.
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Name: Client first name Client last name
Gender:
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Date of Birth:
Date
Do You Have a Social Security Card?
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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?
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Substance(s) of Use:
Client substances of choice
When Was The Last Day You Used?
Date
Are You an I.V. User?
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If You Have Felonies, Pleast List Them Here Honestly: Text field
Are You Currently On Probation?
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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?
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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?
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Are You a Sex Offender?
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Do You Have a VALID Tennessee Driver's License or Tennessee State ID?
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License or ID #: Text field
Do You Have a Current Mental Health Diagnosis?
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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?
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If Yes: Text field
Is Your Family Supportive?
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May We Mention TRC If We Need To Call You?
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Is There Any Information You Can Provide To Assist Us In Your Consideration For Admission?
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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.
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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