Tony Rice Recovery Center - Intake Application for Residential Treatment

Important Intake Information – Please Read Carefully

We’re so proud of you for taking this step toward recovery—you’re almost there! 💙

To make sure your intake process goes smoothly, please remember the following:

All new clients must bring a valid Tennessee ID or Driver’s License.
If you are currently prescribed medication(s), please make arrangements to bring an adequate supply with you.

Please include your full name (or the full name of the person you're assisting) and take your time to provide as much information as possible—this helps us better prepare to support you.

Once your application is submitted, please allow 24–48 hours for review. After that time, we ask that you give us a call to follow up.

Most importantly, we encourage you to be open and honest throughout this process. We are here to help, and every detail you share brings you one step closer to the support you deserve.

With encouragement and care,
The Tony Rice Recovery Center Team

Full Name*

First NameLast Name

Date of Birth*

Date

SSN*

We only ask this to successfully enroll you for grant services upon admission.

Address*

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Phone Number*

Please enter a valid phone number.

Insurance Status (Please Note: We Specifically Serve Tennesseans Who Do Not Have Insurance OR Insurance That Will Not Pay For Treatment)*

No InsuranceSelf-PaySome Insurance, But It Won't Pay For Treatment

Have you ever been a TRC Client before?*

YesNo

Intake Application for Residential Treatment Program