New Patient Registration Form - Florida
Please answer the following questions.  A few are screening questions, and the rest are required demographic and insurance questions.  Thanks for considering us for your mental health needs.
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Email *
Referral Source *
Do you have an insurance deductible for mental health services? *
Location(s) Preferred (choose all you would consider): *
Do you live in Florida?  (We are only allowed to see patients via Telemedicine/Virtual/Video visits who live in the State of Florida.) *
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