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Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Please visit us at www.salemmha.com to learn more about our practice.

Client Information

Legal First Name / Middle Initial

Last Name

Preferred First Name ( optional )

Pronouns ( optional )

Gender Identity ( optional )

Street Address

Street Address 2

City

State

ZIP Code

Cell Phone ( for Text Message Reminders )
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Home Phone
Preferred Contact #

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Emergency Contact

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Last Name

Phone

Mobile

Relation

Street Address

City

State

ZIP Code

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( If client is a minor, the legal guardian must enter their email address below. )

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Salem Mental Health Associates, PLLC - Secure Client Area

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Client Information

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