HRS Clinic / Therapist Account Application
Please complete the form below. After submission, an HRS agent will be contacting you within two business days.
Email address *
First Name *
Your answer
Last Name *
Your answer
Desired Username *
Your answer
Name of Clinic *
Your answer
Street Address (include suite # if applicable) *
Your answer
City / State / Zip *
Your answer
Phone Number *
Your answer
Fax Number
Your answer
How many therapists work at your clinic? *
Your answer
Approximately how many clients do you see? *
Your answer
Have you been selected to participate in Beta Testing? (clinical trial) *
Have you been in contact with one of our agents? *
If "yes" above, provide the name of the agent:
Your answer
Do you consent that we may contact you directly by email or phone once you have submitted this application? *
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