Ithaca Region Therapist Group

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* First Name:

* Last Name:

Preferred Pronouns:

License:

Current Status:

Cost Per Session:

Organization Name:

Website:

Telehealth / In-Person:

Telehealth Only In-Person Only Both

Language(s) Spoken:

Use commas to separate multiple languages.

* I Am:

Group Practice Administrators are responsible for paying the group's membership dues.

* Work Email Address:

This will also be your login username.

* Password:

Minumum 8 characters, must contain an uppercase, lowercase, digit, and special character.

* Re-Type Password:

* Work Phone:

Street Address:

City:

State / Province:

Zip / Postal Code:

* Country:

Upload Photo or Logo:

JPG or PNG format, only.

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Therapist Account Registration