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PLEASE FAX COMPLETED FORM TO INTAKE SPECIALIST (336) 2857868 F FOLLOW-UP CALL MAY BE PLACED TO (336) 2857616PCounseling & Consulting, PLLCREFERRAL FORM Referred By:Referrals Phone:Referring Agency:Referral
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Please fax completed form is a document that needs to be filled out and sent via fax machine.
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