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Affiliate Provider Information Form

Begin Affiliate Provider Information Form Reason for Contact
Provider Name:
Email Address:
Main Phone Number:

Mailing Address Street:
City:
ZIP/Postal Code:
State/Province:

I am working in Private Practice:
I am working for an Organization:
If yes to organization, which organization:
Insurances Accepted (select all that apply):
Which EBT treatment(s) do you provide? (select all that apply):
Training Details (Please provide information on the dates and trainer or each EBT you are trained in. Please also indicate if you participated in a consultation process following the EBT.):