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Referral Form
Thank you for choosing Pinnacle Point Supportive Services LLC.
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Email
*
Your email
Client's Name
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Your answer
Client's D.O.B
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/
DD
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Client's Address (Street Address, City, State, & Zip Code)
*
Your answer
Client's Phone Number
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Your answer
Client's Gender
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Male
Female
Transgender
Client's Race
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African American
Caucasian
Hispanic
Asian
Other
Requested Location
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Corporate Office: 4000 Tuckaseegee Rd Charlotte, NC 28208
Rock Hill SC (Virtual Appointment)
Dillon / East SC: 311 W Harrison St Dillon, SC 29536
Kings Mountain: 608 West Kings St, Bldg. 2 Kings Mountain, NC 28086
Client's Type of Insurance:
Your answer
Client's Insurance Policy # / Group#
Your answer
Guardian's name (If client is under 18 years old)
Your answer
Services Requested
*
Outpatient Therapy
Clinical Assesment
Medication Evaluation
Substanance Abuse Counseling
Medicaid Targeted Case Managment
Psychiatric Evaluations
DWI Services
Esthetic Services
Bariatric Assessments
Other:
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Referring Individual/Agency Name
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Your answer
Referring Individual/Agency Phone Number
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Your answer
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