Providers

Initial Contact

Welcome to The Couch! Please complete the following to get the process started.

First Name

Last Name

Email

Phone

Date of Birth

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License Information

License #

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Training Information

Degree TypeMDDO

Medical Degree

Where did you get your medical degree?

Psychiatry Residency

Where did you earn your residency degree?

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Fellowship / additional training?

What else should we know about you?

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