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1300 Railroad Avenue
Shelbyville, Tennessee 37160
(931) 685-0957
How did you hear about Tony Rice Center?
Secondary Number
Drug(s) of Abuse
TONY RICE
CENTER INC.
INTAKE APPLICATION
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APPLICANT ACKNOWLEDGEMENT AND RELEASE

RIGHT OF APPEAL/GRIEVANCE PROCEDURE: I understand that I may appeal any decision regarding my eligibility for admission to the Program within 14 days of such decision by submitting in writing a grievance to the Executive Director, Cody L. Harris, Tony Rice Center.

CIVIL RIGHTS: I understand that Tony Rice Center Inc is an equal opportunity program open to all eligible persons regardless of age, race, sex, national origin, religion, disability, sexual orientation, or any other class of people protected by any federal, state or local law. If I believe I have been discriminated against I may submit, within 14 days of the event, a written grievance to the Tennessee Board of Mental Health and Developmental Disabilities

NON-TRANSFERABLE: I understand that enrollment is limited to the person(s) named on this application form and is not transferable. Giving my temporary or permanent identification as a Council client to any other person to use will result in my termination from the Program.

LIMITATION OF SERVICES: I understand and acknowledge the following:
A. Services provided by Tony Rice Center Inc are limited to a specific set of routine basic substance abuse treatment services which exclude, among other services, the following: detoxification services,  services provided in the emergency room of a hospital, ambulatory specialty care and intensive inpatient services.
B. A Non-Refundable Intake fee of $100 is required for one person. Fee includes the provision of an ASI assessment and interview by a center clinician.  Payment of the intake fee does not guarantee continued services for any specified time.
C. I understand that specific discharge dates cannot be provided at this time as treatment is based upon clinical subjective factors and applicant's level of participation. Tony Rice center has no obligation to advise me further of the date on which my participation in the program will end. My participation in the Program may be terminated at any time that I am no longer eligible for the Program, as Tony Rice Center may establish general standards for eligibility from time to time.
D. Changes in program expenses, cost of services provides or funding may require modification or termination of the Program at any time; therefore, access to program services even during my enrollment period are not guaranteed.

HOLD HARMLESS:I acknowledge that neither Tony Rice Center Inc, nor any agent or employee thereof, are responsible to me in any way for the amount or quality of medical, mental health or treatment services  which I may receive from any agency from which I am referred..I agree to hold harmless and release Tony Rice Center Inc and its Directors, officers, employees, and agents from any liability arising from its arranging or attempting to arrange medical , mental health or treatment services for me through the referral process.

CERTIFICATION: This Acknowledgement and Release is made in connection with access to services under the Program.
I have been advised of my rights and obligations under the program. I certify that the information I have provided is accurate and complete. Program officials may verify any information provided on this form. I understand that deliberate omission or misrepresentation of any information may result in refusal of admission and/or in my termination from the Program and civil or criminal prosecution under state or federal law.

RELEASE OF INFORMATION: I consent to the release of any and all medical, social, and fi nancial information to Tony Rice Center Inc, its agents, contractors, and service providers with whom it maintains a relationship. I understand that the release of any medical information about me by Tony Rice Centerl is limited by the authorization form, a copy of which would be provided to me. I understand that I cannot become an enrollee of the Program until I agree to this consent and sign appropriate authorization forms.

TONY RICE CENTER IS AN EQUAL OPPORTUNITY PROVIDER, AND EMPLOYER.
County
Do you have any pending court dates or adjudication?
Benzodiazipines
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YesNo
YesNo
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MaleFemale
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YesNo
Alcohol
Cocaine
Marijuana
Opiates
Methanphetamine
Heroin
Sedatives
Steroids
Ectasy
Amphetamines
Inhalents
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