Ebright Client Application Form
The following questions are meant as a pre-screening tool to help us gain a better idea of whether or not our program might be a helpful fit for you. Once you submit this form, someone from Ebright will contact you to further discuss your responses and next steps.
PLEASE NOTE: This form is meant to be completed by the perspective client only.
The following questions will ask for some identifying information so we can contact you (i.e. your first name, last initial, and phone number). This data is securely stored in line with HIPAA and HITECH laws and will not be shared by The Ebright Collaborative LLC.