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Last Name
Email Address
Provider Group Name
Provider Phone Number
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0-30
31-50
51-100
101-150
More than 150
How many active clients/patients does your Provider see?
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Counseling / Psychotherapy
Marriage and Family Therapy
Case management / Social services
Speech and Language Pathology (SLP)
Occupational Therapy
Physical Therapy
Psychiatry / MD
Applied Behavior Analysis (ABA)
Other
What type of Provider best represents yours?
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Yes- non-profit
Yes - school/ college
No
Are you a non-profit or a school/college?
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Telehealth
Private/Group
Nonprofit/Education
Subscription Plan?
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