• I am: *
  Interested in Unyte for my family/myself (I am not a professional) A mental or physical healthcare professional interested in tools for my practice A mental or physical healthcare professional interested in tools for my practice and family
• Please select the primary reason you are seeking support: *
  - Select a Value - Addiction Anxiety Depression Eating Disorder Grief Learning difficulties (ADHD, ADD, etc.) Obsessive-Compulsive (OCD) Physical or chronic illness Pregnancy, Prenatal, Postpartum Relationship or family difficulties Sensory challenges Sexual or Gender Identity Sleep or Insomnia Social difficulties Stress management Trauma and PTSD Traumatic Brain Injury (TBI) Something else I am not sure
• I would prefer my provider to be: *
  - Select a Value - Female Male Non-Binary/Non-Conforming I have no gender preference
• I am looking for a provider who specializes in work with: *
  - Select a Value - Adults Children Teens Mid-life Elderly
• I am specifically looking for a provider who offers: *
  - Select a Value - Mental Health Counseling EMDR Somatic Experiencing Occupational Therapy Physical Therapy CBT Play Therapy Functional Medicine Yoga Therapy Other I don’t have specific requests
• I am looking for my provider to be certified in offering: *
  - Select a Value - Safe and Sound Protocol Focus System Both I have no preference
• I prefer a provider who accepts insurance *
  - Select a Value - Yes No
• My preference for program delivery is: *
  - Select a Value - Remote delivery via virtual platform In person via in-clinic or office I am ok with either remote or in-person delivery

Do you require your provider to be in a specific:

• Country
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• State/Province
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• City

In order to connect you with a provider, please provide us with the following contact information:

• First Name *
• Last Name *
• Email *
• Phone Number
• Best way to contact you (please include time zone):
• Is there anything else you’d like us to know:

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