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RegistrationNew patient information

Please complete the following information for our records. Your information will be transmitted securely using the highest encryption methods possible for your safety.

Name(Required)
MM slash DD slash YYYY
Address

Spouse/Partner (Required if attending session)

If you're attending as an individual, please use "N/A" in the required fields.
Name(Required)
MM slash DD slash YYYY

Consent

Read Policies(Required)
Payment Awareness(Required)
Telehealth(Required)
Authorization(Required)

(Client or authorized party)
MM slash DD slash YYYY
(Attending Spouse or Partner)
MM slash DD slash YYYY