Contact Form

Good Shepherd Recovery House - 601 Moore Rd, Jasper, GA 30143
PO Box 328, Holly Springs, GA 30142-0006 | Phone: 678-459-2346 | Fax: 888-826-6972 | https://gsrecovery.org

Client Information

Client First Name: *

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First Name is Required.

Client Middle Name:

Client Last Name: *

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Last Name is required.

Client Date of Birth: (mm/dd/yyyy) *

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Date of Birth is required.

Client Drug(s) of Choice: *

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Durg(s) of Choice is required.

Incarceration Location (City, County, State): *

Sponsor Information

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Sponsor/Payor Phone: *

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Sponsor/Payor Email:

Emergency Contact Information

Emergency Contact Name: *

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Emergency Contact Phone: *

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Emergency Phone is required.

Emergency Contact Email:

Supervising Officer Information

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Supervising Officer Email:

Lawyer Information

Lawyer Name:

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Client Name is required.

Lawyer Phone:

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Lawyer Email:

Person Inquiring

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Phone: *

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Email:

Where did you hear about us? *

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Message: *

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