First Name
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Last Name
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Organization
*
Phone
*
Email
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I am interested in Clinicom as a:
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Licensed Clinician, Mental Health or community Organization, Payor, Educator, or EAP
Patient
My Role:
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Qualified Health Professional
Clinical Support
Scheduling
Billing
Other
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Credentials
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Medical Doctor Psychiatrist-General
Medical Doctor Psychiatrist-Child & Adolescent
Medical Doctor Psychiatrist-Geriatric Medicine
Medical Doctor General-Practitioner
Medical Doctor-Pediatrician
Medical Doctor-Other
Psychologist PsyD, Psychologist PhD
LPC License Practicing Counselor
Ms Other
BS
LPN
RN
CRNP
Other
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Total number of Clinicians
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1-2
3-5
6-10
11-20
21-50
51-99
100+
Are you involved in the decision-making process for selecting clinical platforms for your organization?
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Yes
No
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Consent Permission
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I consent to communications from Clinicom using the information I have provided,