Intake Request Form

At True Gospel Recovery Center, we believe that everyone deserves a temporary safe place to recover from negative addictive behaviors.

True Gospel Recovery Center Intake Form

Please enable JavaScript in your browser to complete this form.

Name

First

Middle

Last

Date of Birth

Place of Birth

Mother`s Middle Surname

Race

Colour of Eyes

Height

Home Phone

Social security Number

Place Social Eyes

Address

Address Line 1

Address Line 2

City

State

Zip Code

how did you hear about us ?

Do u Have A valid Picture ID

What is Your Driver`s LIcense or ID

Emergency Contact Person Name

Phone

Signature

Clear Signature

File Upload