Clinical Referral | ETX Counseling

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Serving All of East Texas

Longview, TX: 405 Magrill St.

Marshall, TX: 221 East End Blvd Ste B

903-502-0490

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Referral Form to Dr. Skarda

Referring Clinician

Referring Clinician’s preferred means of secure communication/email:

Client First Name*

Client Last Name*

Client's Phone*

Client's Email*

Client's Age

Allergies*

Current doctor/PCP*

Current Medications*

Presenting Issue/Working Diagnosis: *

Additional Comments/Requests

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