Safe & Sound Protocol

Please correct the errors described below.

Please take a moment to fill out this application for our Safe & Sound Program (SSP). We thank all referrers and applicants for your interest and support of this program.

Please provide at least one phone number. Your mobile number can be used to look up your account and receive text message appointment reminders

Refers to current gender which may be different than what is indicated on your insurance policies

Thank you. Your application will be confidentially reviewed by a committee of Clarity Clinic Team Members

Your information will be encrypted.