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Medical Provider Referral List
Are you a medical provider that would like to be added to our referral list? Please fill out this form and we will follow up with you soon.
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Email *
What is your office phone? (to give clients) *
What is your office fax number (optional):
What is a website address we may give clients?
Are you taking new clients? *
What ages do you treat? *
What area of town are you located in? *
Street Address: *
Suite number
City *
Zip code *
How would you prefer us to reach out to you with referrals? *
Do you accept insurance? *
Do you accept any of these? Check all that apply:
What is your service fee? *
What is your area of specialty? *
Are you interested in treating clients with moderate to severe OCD? *
Please rate your comfort treating patients with moderate to severe OCD *
Not comfortable at all
Extremely comfortable
Is there anything you do NOT treat?
Any other information you would like us to know?
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