Welcome. We’re very excited to work with you.

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* 1. Contact information:

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* 2. Website:

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* 3. Role:

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* 4. Who will be sharing assessment results with clients/patients?

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* 5. Treatment and/or services offered (Please check all that apply):

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* 6. Insurance accepted (Please check all that apply):

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* 7. Estimated number of monthly intakes:

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* 8. If there are other's you'd like to add, please do so here.

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* 9. Questions or comments?

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