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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 Full Social Security Number *
Client Date of Birth *
MM
/
DD
/
YYYY
Client Phone Number *
Client Secondary Phone Number
Client Email Address  This is required for accessing our client portal system *
Insurance Type Provider  Check all that apply. *
Required
Is the Insurance plan Commercial, Marketplace, or Medicaid? Check all that apply. *
Required
Has the client ever, or is currently, worked as a First Responder? *
If yes, would they like to participate in the first responder project? This project would allow for copays, deductibles, and other costs not covered by insurance, to be paid by the Kocheran Strong Foundation. No personal health information will be shared with the organization.  *
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