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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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
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Indiana
Iowa
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Maryland
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New York
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington, DC
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What type of service/s are you interested in?
What type of service are you interested in?
Billing Management Services
Credentialing and Contracting Services
Financial and Bookkeeping Services (Launching Soon – Join Waitlist)
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How Did You Hear About Us?
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How Did You Hear About Us?
Search Engine (Google, Bing, etc)
Facebook
Instagram
Word of Mouth
Referral
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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?
In-house biller
Outsourced billing company
Mixed / unsure
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Average Monthly Sessions
<50
50–200
200–500
500+
Primary Pain Point
Lost revenue
Billing errors
Cash-flow instability
Credentialing issues
Poor reporting
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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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