Lane 9 Athlete <> Clinician Match Form
Lane 9 is here to help you build your REDs, Eating Disorder, and/or women's health care team! Our Directory of Providers spans all 50 states, and includes a variety of disciplines. Fill out the form below and we'll match you with a provider and/or care team that fits your needs.

Please note: By providing clinician and/or coach recommendations, we are not guaranteeing any specific outcome or diagnosis from the assessment, treatment, and/or work completed between client and clinician/coach.

Email *
Confirm you email address: *
Please note we will use your email address to connect you with a provider/providers from the Lane 9 directory. 
OPTIONAL: Share any additional information about what you're looking for with a clinician/coach. 
Please do not disclose sensitive personal health information, as this form itself is not HIPAA-compliant. We will not share any information you include here with anyone other than your matched clinician.
By signing with my initials below, I give Lane 9 Project LLC permission to contact me using the email address provided with a clinician from the Lane 9 Directory. Additionally, I acknowledge that by matching and/or working with a clinician or coach from the Lane 9 Directory, Lane 9 Project LLC does not and cannot guarantee any specific health or performance outcome from the assessment, diagnostic, and/or treatment process between you and the clinician(s) and/or coach(es). *
Today's Date *
MM
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Your name: *
City, State *
And we'd love to know how you found Lane 9, if you're open to sharing:
Thanks! Below are just a few questions that will help us match you with a provider from our Directory. 
Type of Practitioner/Clinician you're looking for *
Select all that may apply. We are able to match you with more than one clinician if needed.
Required
Select sport(s) you play/participate in (if any):
Select the level you compete at (if any):
What is your age group?
This helps us match you with a provider who specializes in working with certain age groups/seasons of life.
Select which type of support you're looking for *
Required
Thank you for reaching out to us as you build your care team! We'll be in touch within the next few days.

With any additional questions, don't hesitate to email us: Lane9project@gmail.com
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