Contact Form

	Good Shepherd Recovery House 601 Moore Rd, Jasper, GA 30143 Mailing Address: 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

Sponsor/Payor Name: *

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Sponsor/Payor Name is required.

Sponsor/Payor Phone: *

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Sponsor/Payor Phone is required.

Sponsor/Payor Email:

Emergency Contact Information

Emergency Contact Name: *

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Emergency Name is required.

Emergency Contact Phone: *

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Emergency Phone is required.

Emergency Contact Email:

Supervising Officer Information

Supervising Officer Name:

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Supervising Officer Name is required.

Supervising Officer Phone:

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Supervising Officer Phone is required.

Supervising Officer Email:

Lawyer Information

Lawyer Name:

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Client Name is required.

Lawyer Phone:

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Client Phone is required.

Lawyer Email:

Person Inquiring

Name: *

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Name is required.

Phone: *

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Phone is required.

Email:

Where did you hear about us? *

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required.

Message: *

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Message is required.

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