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{{patient.fName}} {{patient.lName}}

{{provider.practiceName}} {{provider.title}} {{provider.streetAddress}} {{}} {{provider.state}} {{provider.practiceZIP}} {{provider.practicePhone}}


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Current Password New Password Confirm New Password


Messages {{messageCount}}


{{m.posted | date:'shortDate'}} {{provider.practiceName}} {{provider.title}}
Self Reporting
PHQ9 GAD7 PCL5 dsm5 DSM5 Done
Past Medical History [Done]
Past Medical History [Please Fill In]
Contact info
School and Guardians

Guardian 1

Guardian 2

Other Providers/Contacts

Please add all providers, and check box for those you wish to authorize your provider to contact. View Release of Information.

Authorization for {{provider.practiceName}} {{provider.title}} to Use or Disclose My Health Information

You may use or disclose all my health information (including mental health and substance abuse treatment records) maintained by {{provider.practiceName}} {{provider.title}} to [other provider] at my request, for the purpose of coordination or transfer of treatment. I also authorize [other provider] to release my health information (including mental health and substance abuse treatment records) to {{provider.practiceName}} {{provider.title}} for the purpose of coordination and transfer of treatment.This authorization ends when I end my treatment with {{provider.practiceName}}.
My Rights:
  • I understand that I do not have to sign this authorization in order to get health care benefits (treatment).
  • I understand I have a right to a copy of this authorization (available electronically on my patient portal).
  • I may revoke this authorization in writing. If I did, it would not affect any actions taken by {{provider.practiceName}} based upon this authorization. Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.
   {{p.fName}} {{}}   {{(p.type)?p.type:p.specialy}} I have read and agree to Release Of Information

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{{ph.SearchString}} {{ph.phonePrimary}} {{ph.defaultPharmacy | checkmark1state}}
Required Forms
I have read and agreed to {{f.formtitle}} on {{f.dateSigned}}
Recent Statements
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Credit Card {{ccStatus}}
Credit Card On File ending in {{p.CardNumber}}
Billing Address Same as Home


Balance: {{balance | currency}}
{{t.dateAccrued | date: 'shortDate'}} {{t.CPTCode}} {{t.paymentType}} {{t.checkNumber}} {{t.charge | currency: '$'}} {{t.duration}} mins at {{t.rate}} $/hour {{t.comment}}


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Find My Provider
We texted your temporary password to the phone number on file. OK
..working.. 1 Provider {{providers.length}} Providers
RESET {{p.retrieveError}} {{p.statusSuccess}}