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Dirty South Therapeutics Referral Form
Thank you for choosing Dirty South Therapeutics for your behavioral and addiction treatment needs. Please fill out the questions in the form below, and have a great day! If you have any questions, please reach out and call at 740-466-7733, or send an email to info@DirtySouthTherapeutics.org
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Client Full Legal Name *
Client Chosen Name
Client Pronouns *
Required
Client Gender Identity *
Required
Client Assigned Gender At Birth or Legal Gender. This information is used for billing purposes only. Client gender identity will always be respected and affirmed. *
Client Social Security Number *
Client Date of Birth *
MM
/
DD
/
YYYY
Client Phone Number *
Client Secondary Phone Number
Client Email Address *
Insurance Type Provider  Check all that apply. *
Required
Is the Insurance plan Commercial, Marketplace, or Medicaid? Check all that apply. *
Required
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