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* 1. Name

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* 2. Email

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* 3. Phone

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* 4. How has your experience been with the CYBHI fee schedule program? Have you been able to successfully become a designated community-based school-linked provider/practitioner with a Local Educational Agency (LEA) or institution of higher education (IHE)? Please be as specific as possible on any questions or challenges you have with your participation in the program.

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