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First Name
Last Name
Email
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Phone
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Practice / Company Name (if applicable)
Your Role in the Practice (if applicable)
State of Practice
What type of service/s are you interested in? (IOP/PHP not supported)
What type of service are you interested in?
How Did You Hear About Us?
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How Did You Hear About Us?
Are you an established mental health practice currently seeing patients?
Yes
No
Practice Type
Solo Practice
Group Practice
License Type (Select All that Apply)
Psychiatrist (MD/DO)
PMHNP
Psychologist
Psychotherapist (LMFT/LCSW/LPCC)
How are you currently handling billing?
Average Monthly Sessions
<50
50–200
200–500
500+
Primary Pain Point
Years in Operation
1–2 years
3–5 years
5+ years
Ready to switch billing services within 30–90 days?
Yes
No
Additional notes or comments (optional)
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