Registration Request for GPS

This form is encrypted and HIPAA compliant

Please enter the information below. You will get an email from "Therapy Portal" This information you are providing will verify your identity the first time you create an account. Your intake paperwork will be in the portal after you register.

Name

Email address

Birth Date

Area Code

Phone Number

Please upload Driver License or ID

Add file

Please upload a file

Please upload front and back of your Insurance Card

Add file

Please upload a file

Your information will be encrypted.

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