HRA Psychological Services PC

Security Check

Instructions: Please enter your information in the section below. If a minor is to be seen/evaluated, please enter their information. Please enter one request per child. When finished click "Proceed to Registrati

First Name:*

Last Name:*

DOB:*

Sex:*

E-mail:*

Mobile #:*

Home Phone #:

Address:*

Zip Code:*

Patient Availability:

Days:

Sun Mon Tue Wed Thu Fri Sat

Referral Source:

Reason for Visit:*

Facility:*

Get email instructions in:

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Once clicking "Proceed to Registration", you can complete your registration now or return to complete it later by clicking the link in the initial email you received.

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Once clicking "Proceed to Registration", you can complete your registration now or return to complete it later by clicking the link in the initial email you received.

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You can even make Google Chrome as your default browser.
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If you want to see the step-by-step process to download
Google Chrome, click on the Download PDF button.

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