No More Tears Recovery Intake Form

Please fill out the form below to be considered for our twelve-step back-to-work program

First name*

Last name*

Birthday*

Month

Day

Year

Phone*

Can you work a 40-hour work week?*

Yes

Are you a sex offender?*

Yes

Have you ever been charged with or convicted of a sex related crime?

Have you ever been convicted of arson?*

Yes

Do you have two forms of government ID?*

Yes

What medications are you on? (Include all medication prescribed to you)*

Mental Health Diagnosis?*

Are you HIV Positive?*

Yes

Are you able to pay your $500 intake fee?*

Your intake fee covers your first week's rent and your drug testing for your stay in our six month program.

When do you complete treatment?*

Month

Day

Year

If you are not coming from a treatment program, please enter the date you desire to become a resident. If you are coming from a treatment program, you must complete the program before you come here. We do not take individuals who want to leave treatment early.

Short paragraph on why you think this program is a good fit for you*

Upon your completion of this form, you will receive a call from us to conduct your phone interview.

NO MORE TEARS RECOVERY, INC.

Waverly, TN

For admissions, contact one of these numbers. We respond as quickly as humanly possible:

Mitchell Ross, Founder and CEO: 615-715-3141; mitchell@nomoretearsrecovery.com

Richard Morris, CFO: 615-618-6557; richard@nomoretearsrecovery.com

Kelli Fritts, COO: kelli@nomoretearsrecovery.com

Richard Caksackkar, VP of Ops: 931-320-1677; richardc@nomoretearsrecovery.com

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