First name*

Last name*

Company Name*

Company Email*

Direct Phone Number*

State/Region

Are you currently a Lightning Step client?*

Yes

No

If not, what EMR are you currently using?

What levels of care does your facility provide?

Detox

Residential

IOP

OP

PHP

Sober Living

Physical Health

High Intensity Out Patient

MAT OTP

Primary Care

Foster Care

What types of services does your facility provide?

Behavioral Health

Mental Health

Substance Abuse

Psychiatric Care

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