• Patient Registration

    Welcome! Please complete this form, read all documents carefully, and sign them where indicated. Note: You are not required to complete your paperwork electronically. If you would prefer paper copies to be mailed to you, please call us at (919) 600-4906. Please remember, however, that we must receive your completed and signed paperwork prior to seeing you.
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  • Electronic Communications Options

    You have two options for electronic communication with us: Patient Ally and direct email-to-email.

    Patient Ally: is our secure patient portal that you can use to send documents to us and receive documents from us securely. Patient Ally is more secure than email communication because you will have to register for the service and log in each time you access it. If you would like to sign up for Patient Ally, you will receive an emailed invitation to register for the service. 

    Email only: Many patients prefer the convenience of unsecured email, but email is not considered to be a confidential means of communication. While our electronic systems are secured, information is no longer protected by our systems once an email is sent. Information may be vulnerable while in transit and after it is received by your email server. The kinds of parties that may intercept these messages include, but are not limited to:
    • People in your home, work, or other environments who can access your device
    • Your employer, if you use your work email to communicate with us
    • Third parties such as server administrators and others who monitor internet traffic
    • People who may “hack” email or computer

    IMPORTANT: If you choose Patient Ally only, we cannot directly email you from this point forward (unless you have chosen to receive emailed appointment reminders). If you choose email only, you understand that you may receive documents and other communication that may contain your protected health information (PHI). You may change your preferences at any time by calling us at (919) 600-4906.

  • The option you chose means that we cannot send you any other electronic forms to complete, we cannot administer any remote psychological testing, and we cannot get any of your records or test results to you electronically.

    If you are concerned about security, we recommend you choose the Patient Ally option, but we will also honor your choice if you only want to use postal mail or in-person to send and receive documents that may identify you as our patient or contain your protected health information. 

    If you choose to receive emailed appointment reminders below, we will still send your appointment reminders by email, but no other information will be sent to your email address from this point forward. 

  • A parent or legally appointed guardian must be physically present with a minor patient, whether the minor is being seen by telehealth or in our office.

    This form must be completed by the same parent or legally appointed guardian who will be accompanying the child to the appointment. 

  • Note: You are only a legally dependent adult for this purpose if you have been deemed mentally incapable of making healthcare decisions for yourself and a judge in a court of law has signed paperwork stating as such. 

    A court-appointed guardian of person must physically accompany a dependent adult to their appointment, whether the adult is being seen by telehealth or in the office.

    Legal guardians must provide court appointment paperwork verifying their legal authority to consent to medical services for the patient as well as proper identification. If a legal guardian does not accompany the dependent adult to the appointment, we will not be able to see the patient. 

    Note that a legal guardian is not the same as a healthcare power of attorney. We will honor a healthcare power of attorney document if the patient lacks sufficient understanding or capacity to make or communicate healthcare decisions. Only the physician, psychologist, or other person designated by the patient in the health care power of attorney may certify, in writing, acknowledged before a notary public, that the principal lacks sufficient understanding or capacity to make or communicate decisions relating to their health care. 

  • You have indicated that you are a court-appointed legal guardian over this minor patient. Because of the sensitive nature of mental health services, we require a copy of the court order at least 3 days prior to the scheduled appointment. You may send the court order by email to info@etheridgepsychology.com or by fax to (888) 887-6361. 

  • You have indicated that you are a stepparent to this minor patient. Please do not proceed further and have a parent or legally appointed guardian complete this paperwork. We apologize for the inconvenience.

    If you have been court-appointed as a legal guardian over this patient, please go back and choose "court-appointed legal guardian." 

  • You have indicated "other relationship" to this minor patient. Please do not proceed further and have a parent or legally appointed guardian complete this paperwork. We apologize for the inconvenience

    If you have been court-appointed as a legal guardian over this patient, please go back and choose "court-appointed legal guardian."

  • Due to the sensitive nature of mental health services, we must be diligent about obtaining proper informed consent when treating or evaluating a minor child. When the child's parents are not living together, we require one of two things at least 72 hours prior to the appointment to be able to see the child:

    EITHER: A copy of the current child custody court order.

    OR: This informed consent document completed in full by both parents. 

    If we do not receive this, we cannot see your child and the appointment will be cancelled. 

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  • The next few documents are important.

    Please read them carefully, scrolling through as needed.

    Your signed consent and agreement are required for us to be able to serve you. 

  • INFORMED CONSENT FOR PSYCHOLOGICAL SERVICES

    OUR SERVICES
    We provide two main types of clinical psychological services: psychological evaluations and psychotherapy.

    Psychological evaluations are designed to answer a question, such as whether you have a mental health diagnosis, what your personality style is, or how good your memory is. A psychological evaluation is not treatment. Psychological evaluations involve a clinical interview and, often, administration of psychological tests. We may also request, with your written consent, to review certain records and/or communicate with others who know you well.

    Psychotherapy is to help you identify sources of emotional discomfort, develop a plan of action, and ultimately reduce that discomfort. Psychotherapy involves an initial evaluation and may involve education, support, talking about feelings, changing negative thought patterns, and changing your behavior. A diagnosis is usually given by the clinician.

    BENEFITS/RISKS
    A psychological evaluation may be beneficial in that it may result in a diagnosis that can then be used for treatment planning with the goal that your symptoms improve. It may rule out a mental disorder that was suspected. Psychotherapy can help you to find solutions to specific problems, reduce feelings of emotional distress, and improve relationships.

    Talking with a clinician can produce uncomfortable feelings. Making even positive changes can be disruptive to the relationships in your life. We cannot guarantee that your services will result in external gain such as disability benefits or academic accommodations, and we cannot guarantee that a particular diagnosis will or will not be given.

    MEETINGS
    A psychological evaluation may involve 1 to 3 or more appointments. If tests are ordered, the clinician may give them immediately or schedule for a later date. Test results are not available immediately, and a final written report may take one to several weeks. During a final feedback session, we will go over the results, diagnosis (if rendered), and recommendations.

    Psychotherapy generally begins with an initial intake session that can last 45-60 minutes. Subsequent psychotherapy sessions last from 38-55 minutes if you have insurance; they can be longer if you pay out-of-pocket. The frequency and length of sessions should be agreed upon during your meeting with your clinician.

    ENDING SERVICES
    A psychological evaluation is complete when you have your final feedback session. You are usually the one who decides when therapy will end. We cannot determine before meeting with you whether we can help you, but if we cannot, we will discuss it with you and refer you to a provider who may be a better fit. We may also discuss termination of services for reasons such as: treatment not progressing, chronic lateness or no-shows, or inability to pay, although we will work with you on payment arrangements. We will provide you with referrals to other sources of care.

    BEHAVIORAL POLICY
    You are encouraged to express your feelings, good or bad, with your clinician, and we maintain a peaceful practice where visitors and staff feel safe. That said, we do not tolerate any sort of abuse, whether in person, telephonic, by email, or by any other means. We will immediately terminate services if you (or anyone else acting on your behalf) verbally attack, threaten, stalk, harass, or are aggressive or violent toward any staff member, visitor, or anyone else associated with us. If necessary, we will contact law enforcement and seek legal assistance, and this will compromise your confidentiality.

    CONTACTING US
    The best way to reach us is by telephone at (919) 600-4906. We are an office-based mental health practice. We are not equipped as a crisis facility and cannot provide immediate or walk-in services, although we will see you as quickly as possible. If you are unable to reach us and are in a life-threatening situation, call 911 or go to the nearest emergency room. We also have a list of community crisis resources on our website.

    PROFESSIONAL RECORDS
    All the information you provide will go into an electronic clinical record along with our notes, diagnosis, treatment provided, recommendations made, and any other information about our work with you. If your record is to be released to a third party, that party will be privy to the information contained within. We are required to keep your records for a certain number of years. You are entitled to receive a copy of the records unless your clinician believes that seeing them could be emotionally damaging, in which case we will send them to another licensed mental health professional. Your clinician may insist that you review your records in the clinician’s presence before a copy will be released to you, and you will be charged our regular clinical rates for the meeting. Test data and results may be released to you, but test materials will not. Please refer to our HIPAA Privacy Notice for more information.

    CONFIDENTIALITY
    In general, the privacy of all communications between a patient and a licensed mental health professional is protected by law, and we can only release information about our work to others with your written permission with a few exceptions. Your privacy is of utmost importance to us. Please read the following carefully:

    ·   If we file a health insurance claim for you, you must agree to allow us to release any information to your insurance that they need. In rare cases, your insurance company may ask for a copy of your entire clinical record.

    ·   A court order may compel us to release your clinical records or to testify in court about you.

    ·   We are legally obligated to file a report or contact law enforcement if we believe or you disclose that any child, elderly person, or disabled person is being abused or neglected.

    ·   If we believe that you are at serious risk of harming yourself or another person, we are required by law to act. This may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.

    ·   If you are a minor or are an adult with a court-appointed guardian, please be aware that the law provides your parents or guardian the right to examine your medical records.

    More information about confidentiality can be found in our HIPAA Privacy Notice. Please discuss any questions or concerns about confidentiality with your clinician. That said, we cannot provide you with any legal advice.

  • Electronic Signature

    By completing the following fields, you affirm that you have read this document, that you agree to the terms and conditions, and that you consent to sign this document electronically. You are not required to sign electronically and may request this document in non-electronic form. You have the right to withdraw your consent to further electronic disclosures, in writing, at any time. You have the right to receive a copy of your completed form. You may reach us by phone at (919) 600-4906, and our address is 115 Kildaire Park Dr Ste 313, Cary, NC 27518. If you are signing this document on behalf of a legal dependent (such as a minor child), you attest that you have the legal authority to sign on behalf of this patient without the approval of another person (such as a minor's other parent).

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  • FINANCIAL POLICIES

    Thank you for choosing Etheridge Psychology, P.A. This document outlines important information about our financial policies to avoid any miscommunication. Please read it carefully and contact us with any questions or concerns.

    NEW PATIENT DEPOSIT

    A $40 deposit is required for new patients to reserve their appointment unless otherwise noted below. The deposit is applied to your fees or refunded to you once a third party pays the entire balance. If you miss the appointment or provide less than 24 hours’ notice to cancel or reschedule, your deposit is forfeited, and a new deposit is required to schedule with us again.

    PAYMENT IN FULL IS DUE ON THE DATE OF SERVICE 

    Payment (or your expected portion of costs when using insurance) is due on the date of service. For a self-pay evaluation, you may pay 50% of the expected cost at the first appointment. The remaining balance is due at your final appointment.

    We will not complete a written evaluation report until we receive payment in full, whether that payment comes from you, your insurance company, or other responsible party. You are still entitled to a copy of any records already produced.  

    HEALTH INSURANCE

    It is your responsibility to know your benefits and to provide us with the information we need to file your claim. We may verify benefits prior to appointments, but we are not required to do so and are sometimes unable to reach a representative. If we are unable to verify your benefits, you must pay in full. If you do not tell us about your insurance until after the service has been rendered, we cannot file your claim.

    Any benefits information we relay to you has come from your insurance company. We cannot guarantee that your insurance company will reimburse us and are not responsible if they do not pay, even if the insurance company has told us the service is covered and/or has misquoted your benefits.

    Our contracts with health insurance companies forbid us to file claims under certain circumstances, and we will inform you as soon as we become aware. You may elect to proceed at our self-pay rates by signing a non-covered services agreement.

    BILLING STATEMENTS

    You may receive a bill from us, such as when your insurance company does not pay as expected. You are responsible for paying your balance to us and must direct any dispute to your insurance company.

    Billing statements are due upon receipt. If you have requested emailed statements, it is your responsibility to check your spam folder to ensure you receive them. Otherwise, you must ensure we have your current mailing address.

    Accounts overdue for more than 60 days are forwarded to a collection agency. We will release only the information about you that is needed to pursue the debt. If small claims court is necessary, its costs will be included.

    If you are experiencing financial hardship, we can make a payment arrangement with you.

    OUT-OF-POCKET (SELF-PAY) FEES FOR SERVICES

    Licensed Clinical Mental Health Counselors and Licensed Psychological Associates:
    Initial Evaluation/Intake (30-60 min)  $200 
    Psychotherapy (38-min minimum)      $150
    Psychotherapy (53-min minimum)      $175

    Licensed Psychologists:
    Initial Evaluation/Intake (30-60 min)   $225
    Psychotherapy (38 min minimum)       $175
    Psychotherapy (53 min minimum)       $200
    Psychological Evaluation (per hour)     $200*
    *Includes the psychologist’s time meeting with you, obtaining and reviewing collateral information, administering, scoring, and interpreting tests, and preparing a written report. Your clinician spends a lot of time on your evaluation when you are not present! 

    To help you plan financially, following is a list of estimated total fees for various types of evaluations we offer. Sometimes, more extensive testing is required at additional cost, and we cannot know that before seeing you.

    ESTIMATED TOTAL FEES FOR EVALUATIONS

    Important: These fees DO NOT APPLY to any evaluation done for a legal purpose.

    ADHD Evaluation   $950
    Most Clinical and Neuropsychological Evaluations   $900
    Autism Evaluation   $1700+
    Pre-Bariatric Surgery Psychological Evaluation   $500
    Learning Disorder Evaluation   $1100*
    Early Entry into Kindergarten Testing   $650*
    IQ Testing only   $500

    *$75 deposit required upon scheduling

    OTHER FEES

    This list is not meant to be exhaustive. If what you need is not addressed in this document, you and your clinician may come to an agreement prior to the service being performed unless the service is provided in an emergency situation.

    Missed appointments or rescheduled/cancelled appointments with less than 24 hours’ notice: $40 PER HOUR of clinician’s time reserved

    Lost testing materials: $3 per replaced test

    Returned/bounced checks: $25 administrative fee

    Writing letters or completing forms upon request: $50 minimum, $200.00 per hour, billed in 15-min increments

    Telephone calls or emails with or concerning patient: 0-14 minutes of clinician’s time: no charge; 15+ minutes: $200.00 per hour, billed in 15-min increments

    Photocopying, printing of documents: $0.15 per page (no charge for one copy of clinical records)

    Attendance at a school-related meeting, classroom observation by clinician, or other off-site service: $200.00 per hour, 1 hour minimum, billed port to port (travel time). After the 1st hour, billed in 15-minute increments.

    Court-related services, such as depositions, consultations with attorneys, trial preparation, court appearance and/or testimony: $250.00 per hour, port to port (travel time), billed in 5-minute increments, paid in advance. A deposition or court appearance requires advance payment equal to the amount of time the clinician must reserve, with a minimum of four hours.

  • Electronic Signature

    By completing the following fields, you affirm that you have read this document, that you agree to the terms and conditions, and that you consent to sign this document electronically. You are not required to sign electronically and may request this document in non-electronic form. You have the right to withdraw your consent to further electronic disclosures, in writing, at any time. You have the right to receive a copy of your completed form. You may reach us by phone at (919) 600-4906, and our address is 115 Kildaire Park Dr Ste 313, Cary, NC 27518. If you are signing this document on behalf of a legal dependent (such as a minor child), you attest that you have the legal authority to sign on behalf of this patient without the approval of another person (such as a minor's other parent).

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  • HIPAA PRIVACY NOTICE

    Policies and Practices to Protect the Privacy of your Health Information

    IN COMPLIANCE WITH THE HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA), THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    Definitions:

    Etheridge Psychology, P.A. – Unless otherwise specified, Etheridge Psychology, P.A., or pronouns such as “We,” “Us,” or “Our”, refers to the above-named practice and its employees, volunteers, and related personnel.

    “You” – Refers to the patient or the patient’s legally authorized personal representative.

    Protected Health Information (PHI) – Information in your health record that could identify you. With certain limited exceptions, PHI is generally defined as information that identifies an individual or that reasonably can be used to identify an individual, and that relates to the individual’s past, present, or future health or condition, healthcare provided to the individual, or the past, present, or future payment for healthcare provided to the individual.

    Use – Applies to activities within our practice such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

    Disclosure – Applies to activities outside our practice, such as releasing, transferring, or providing access to information about you to other parties.

    Authorization – Your written permission to disclose confidential mental health information.

    I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

    We may use or disclose your Protected Health Information (PHI), for:

    Treatment – When we provide, coordinate, or manage your health care and other services related to your health care. Example: A psychologist who has evaluated you may need to tell your family doctor that you have an anxiety disorder that is affecting your sleep or that may be causing your stomachaches or headaches. A therapist who is treating you may need to tell your psychiatrist that you are experiencing a manic episode so that the psychiatrist can adjust your medications.

    Payment – When we obtain reimbursement for your healthcare. Examples: We may disclose your PHI to your health insurer to obtain preauthorization for your treatment or to obtain reimbursement for your health care. We may disclose limited PHI to a collection agency to collect payment for a delinquent balance.

    Health Care Operations – Activities that relate to the performance and operation of this practice. Examples of this are quality assessment/improvement activities and business-related matters such as audits/administrative services. We may use outside individuals or companies (business associates) to perform services for us (e.g., scanning, accounting, legal, technology, and test scoring services). We require these business associates to safeguard your health information.

    II. Other Uses and Disclosures Requiring Authorization

    Etheridge Psychology, P.A. may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained unless required by law (see section IV). Psychotherapy notes are different from and not included in PHI and include notes that have been made about the content of an individual, group, joint, or family therapy session. We will obtain an authorization from you before using or disclosing PHI in a way that is not described in this notice.

    III. Revocation of Authorization

    You may revoke all or any authorizations of PHI and/or psychotherapy notes at any time, provided each revocation is in writing. You may not revoke and authorization to the extent that 1) we have relied on that authorization; or 2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

    IV. Uses and Disclosures without Authorization

    We may use and disclose your PHI to contact you about appointments, treatment, or other communications. We may contact you by any method you provide to us, which may include mail, telephone, or email.

    We will disclose your PHI when required by federal, state, or local law or other judicial or administrative proceeding without your consent or authorization. Following are examples:

    Child Abuse – If you give us information that leads us to suspect child abuse, neglect, or death due to maltreatment of any child, we must report such information to the county Department of Social Services (DSS) or law enforcement if after hours. If asked by DSS to turn over information from your records relevant to a child protective services investigation, we must do so. We will inform you a report has been made unless we believe that informing you may place the individual at risk of serious harm.

    Adult and Domestic Abuse – If you provide us with information that leads to reasonable belief that any disabled adult needs protective services because of abuse or neglect by themselves or another person, we must immediately report this to the Department of Social Services. We will inform you a report has been made unless we believe that informing you may place the individual at risk of serious harm.

    Health Oversight Activities – The North Carolina Psychology Board and other professional boards have the authority to receive relevant records, including your entire clinical record, should we be the focus of an inquiry.

    Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about the professional services we provided you and/or your clinical records, we will not release such information without your written authorization or a court order. If a court order requires that your records be released, under law we must release them, even without your written consent or authorization. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

    Serious Threat to Health or Safety – If we believe disclosure of PHI is necessary to protect you or another individual from a substantial risk of imminent and serious physical injury, we will disclose the PHI to the appropriate individuals, which may include but is not limited to family members, police, or the individual at risk of harm. For example, if you tell your therapist that you plan to poison your spouse, we may notify your spouse as well as law enforcement. If you lose consciousness or become injured while at our practice, we will seek medical care for you and disclose any necessary PHI (e.g., that you have diabetes or a heart condition).

    Worker’s Compensation – If you file a worker’s compensation claim, we are required by law to provide your mental health information relevant to the claim to your employer and the North Carolina Industrial Commission.

    When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the Privacy Rule and the state’s confidentiality law - This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

    V. Patient’s Rights and Our Duties

    Patient’s Rights:

    You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you request.

    You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. For example, you may not want a family member to know you are seeing a mental health professional. At your request, we will send your bills to another address.

    You have a right to inspect and/or obtain a copy of PHI in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances. In some cases, you may have this decision reviewed. You may be denied access to psychotherapy notes if we believe that a limitation of access is necessary to protect you from a substantial risk of imminent psychological impairment or to protect you or another individual from a substantial risk of imminent and serious physical injury. We will notify you or your representatives if we do not grant complete access. On your request, we will discuss with you the details of the request and/or denial process.

    You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.

    You generally have the right to receive an accounting of disclosures of PHI. Upon your request, we will discuss with you the details of the accounting process.

    You have the right to obtain a paper copy of this notice from us.

    You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket for our services.

    You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) our risk assessment fails to determine that there is a low probability that your PHI has been compromised.

    Our Duties:

    We are required by law to maintain the privacy of PHI, to provide you with notice of our legal duties and privacy practices with respect to PHI, and to notify you following a breach of unsecured PHI.

    We are required to comply with the provisions of this notice and only use and/or disclose your health information as described in this notice.

    We will explain how, when, and why we use and/or disclose your health information.

    We reserve the right to change the privacy policies and practices described in this notice and to make the new notice provisions effective for all PHI we maintain. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect (as described in this document). If we revise this notice, the new notice will be effective

    If we revise the terms of this notice, we will provide you with a revised notice in writing either by mail or in person during a regularly scheduled appointment, post it at our office, and upload it to our website.

    VI. Questions and Complaints

    If you have questions about this notice, disagree with a decision we make about access to your records, or have concerns about your privacy rights, you may contact Etheridge Psychology, P.A. directly by phone at (919) 600-4906, or in writing at 115 Kildaire Park Drive, Suite 313, Cary, NC 27518.

    If you believe that your privacy rights have been violated and wish to file a complaint with our office, you may send your written complaint to the address provided above. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. You have specific rights under the Privacy Rule. We will not retaliate against you for exercising your right to file a complaint.

    VII. Effective Date, Restrictions and Changes to Privacy Policy

    This notice went into effect on 4/28/09. It was updated on 3/11/14, 12/29/14, 3/3/16, and 10/7/19.

    We are happy to give you a paper copy of this notice. Please ask.

  • Electronic Signature

    By completing the following fields, you affirm that you are consenting to sign this document electronically and that you have been presented with the HIPAA Privacy Policy. You have the right to obtain, complete, and sign this document in non-electronic form. You have the right to withdraw your consent to further electronic disclosures, in writing, at any time. You have the right to receive a copy of your completed form, either by email or by postal mail. You may reach us by phone at (919) 600-4906, and our physical and mailing address is 115 Kildaire Park Dr Ste 313, Cary, NC 27518. This form is accessible through any device with an internet connection and web browser. If you are signing this document on behalf of a legal dependent (such as a minor child), you attest that you have the legal authority to sign on behalf of this patient without the approval of another person (such as a minor's other parent).

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