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Full Name
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First Name
Last Name
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2
Email Address
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example@example.com
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3
License type, number, and state of licensure
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4
Which best describes the kind of support you’re seeking?
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Starting a private practice
Adding supervision to an existing practice
Strengthening the structure of an existing practice
More than one of the above
Not sure yet
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5
What have you already completed?
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Practice setup steps
Supervisor training/certification
Practice paperwork or policies
EHR / documentation systems
Insurance credentialing
None of the above
Other
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6
Tell me about your current situation, what’s prompting you to reach out, and what you specifically want help with.
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(Examples: business/practice structure, policies, paperwork, etc.)
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7
Anything else I should know before our session?
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