Information Request

Information about person submitting this request for information.

First Name:

Middle Name:

Last Name:

Relationship to patient:

Street Address (line1):

Street Address (line2):

City:		State: Zip:

Country:

Phone Number(s) please provide a number that is appropriate to call when an Intake Counselor contacts you

Home Phone:

Best time to call:

Work Phone:		Extension:

Best time to call:

Mobile Number:

Best time to call:

Is it okay to contact you?		Yes: No:

Email Address:

How did you learn about Talbott Recovery Campus?

Patient Information

First Name:

Middle Name:

Last Name:

Social Security Number:		- -

Date of Birth:

Gender:		Male: Female:

Street Address (line1):

Street Address (line2):

City:		State: Zip:

Country:

Phone Number:

Marital Status:		Never been married: Married: Divorced: Separated: Widowed:

Questions/Comments:



For additional information please call our Admissions Department at: Toll Free: (800) 445-4232 Local: 770-994-0185

Talbott Recovery Campus is owned and operated by a subsidiary of Universal Health Services, one of the nation's leading hospital management companies. For more information on the company, visit http://www.uhsinc.com

Talbott Recovery Campus offers compassionate and comprehensive care for addiction to patients, families and communities. Our commitment to provide superior service and individualized treatment by a knowledgeable, skilled and caring professional staff is stronger than ever. While we are known as the setting where healers come to be healed, our alcohol and chemical dependency treatment facility accepts patients with alcohol addiction, drug addiction and dual-diagnosis. Site by: