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* 1. Please enter your full name as you want listed, including your designations (e.g. MD, CCFP or FRCPC etc.)

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* 2. Please indicate your contact information that will be provided to prospective patients:

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* 3. What gender do you identify as?

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* 4. Please indicate your practice location: (NOTE: Even though therapy will start as remote, some patients may want the option of in-person follow-up after the pandemic is over)

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* 5. Which of the following conditions are you comfortable treating? Check all that apply.

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* 6. Please indicate the type of therapy that you are able to offer. Check all that apply.

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* 7. Please indicate which groups you feel comfortable treating. Check all that apply

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* 8. Please indicate the number of planned sessions per new patient:

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