Please let us know who you are so that we can set up your clinic's online assessment and assign an ID number. We look forward to working with you.

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* 1. Contact information:

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* 2. Primary contact's position:

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

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* 4. Treatment and/or services offered:

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* 5. Estimated number of monthly intakes:

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* 6. If there are others you'd like to add, please do so here.

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* 7. How can we help you? Questions or comments?

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