Ebright Collaborative, LLC Admissions Screening Form
The following questions will help us determine if our program is a good fit for you. After submitting this form, an Ebright team member will contact you about next steps. 

You'll be asked for basic identifying information (name and number) so we can reach you. Your data is securely stored according to HIPAA and HITECH laws and will not be shared.   

PLEASE NOTE: This form is meant to be completed by the perspective client only.

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