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Child/Teen Therapy Screen

A green and white Confirm Signature box will pop up once the form is finished. Make sure to check the box and confirm your signature to complete the form and send it to our office. You will see a final confirmation screen with our office logo once the form has been properly submitted. **Please note, automatic reminders will be sent if a form is open/started but not completed. Please only start/complete one form.**

*mandatory fields