ADI Pediatric Behavioral Health

Instructions: Please enter your information in the section below. When finished, click “Proceed to Registration” to create your username and password.
***Please call 9-1-1 in case of emergency.***

First Name:*

Last Name:*

DOB:*

Sex:*

E-mail:*

Mobile #:*

Home Phone #:

Address:*

Zip Code:*

Patient Availability:*

Days:

Sun Mon Tue Wed Thu Fri Sat

Referral Source:*

Reason for Visit:*

Facility:

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Once clicking "Proceed to Registration", you can complete your registration now or return to complete it later by clicking the link in the initial email you received.

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Once clicking "Proceed to Registration", you can complete your registration now or return to complete it later by clicking the link in the initial email you received.

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If you want to see the step-by-step process to download
Google Chrome, click on the Download PDF button.

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