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


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Date of Birth:



Do You Have a Social Security Card?

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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?


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?



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.


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