Account Info

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Name*
E-mail*
Website

Contact Info

Phone Number
Mobile Number
Fax Number
E-mail
Website
Location*
Address Line 1
City
State / Province / Region
Postal / Zip Code
Country
Latitude
Longitude

Essential Info

Practitioner's Name*
therapist/organization name
Additional practitioners
optional add if there is a second name/affiliated organizations
Practitioner type
Practitioners type or category, services provided etc..
Support patients coming off psychiatric drugs ?
Do you help patients coming off psychiatric drugs if its is appropriate ?
Comments about supporting patients coming off of psychiatric drugs.
Any comments about supporting patients coming off of psychiatric drugs, such as under what conditions, procedure etc.
Other Notes

Social Accounts

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Additional Info

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