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Connell & Associates Website Form
Answer a few questions so we can figure out how to best assist you.
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1
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jotform@oria.health
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2
Are you a
provider
or a
patient
?
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Provider
Patient
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3
What is your name?
*
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First Name
Last Name
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4
What is your license type?
*
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5
What is your email address?
*
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example@example.com
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6
Are you looking for full or part-time hours?
*
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Full-Time
Part -Time
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7
Where are you currently practicing?
*
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Online
Hospital or Clinic
School Counseling
Community Mental Health
Private Practice
Not Currently Practicing
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8
How did you hear about Connell & Associates?
*
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Friend
Doctor Referral
Colleague
Online Search
Social Media
Other
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9
Upload Your Resume!
(This is optional.)
Drag and drop files here
Select files to upload
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10
When's the best time for an interview?
Day, time of day, etc. And please include timezone!
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11
I'm looking for services for...
*
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Myself
My Child
My Partner and Myself
My Family
Other
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12
Are the patient? Or are you the patient's guardian?
*
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Patient
Guardian
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13
Hi, guardian! What's
your
name?
*
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First Name
Last Name
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14
What is the
patient's
name?
*
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First Name
Last Name
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15
What is the
patient's
date of birth?
*
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16
What is your email address?
*
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example@example.com
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17
What is the best phone number at which to reach you?
*
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Area Code
Phone Number
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18
Which of these are you looking for?
*
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Choose all that apply.
Therapy
Medication Management
Psychological Testing Services
Unsure
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19
Will you be using insurance?
*
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Yes
No
Unsure
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20
Insurance information
*
This field is required.
To better serve you, please include the Insurance company, Member ID, Group Number, and Co-Pay amount if known.
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21
What concerns would you like to address with a provider?
*
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Tell us as much or as little as you'd like.
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22
Do you already have a provider in mind?
*
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If so, who?
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23
When's the best time for you to meet with a provider?
*
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Day, time of day, etc. And please include timezone!
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24
How did you hear about Connell & Associates?
*
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Friend
Doctor Referral
Colleague
Online Search
Social Media
Other
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