620 W. Grand Ave., Ponca City, OK 74601
580-762-1462, option 0 for the front desk. Fax: 580-765-7229

Referral

Bridgeway Inc. agree that such information may not be used for any purpose other than the purposes stated in this agreement and that any other use or release to any party of such confidential information or records without prior written consent, will be presumed to be a breach of this Confidentiality Agreement.

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Name of person making the referral
Client Name
Substances they use
Previous treatments?
The type of treatment you are seeking

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