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CPTSD Quiz

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Reason for Contact**

Permission to Contact

Permission to call you

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By leaving this box checked you acknowledge and give your permission for one of our team members at The Raleigh House to contact you with the information you provided.

Consent*

I request and consent to The Raleigh House communicating with me using email. I understand that such communications may include my personal medical information, will not be encrypted, may be intercepted or alternated in transmission, and may be viewed by others with access to my email account or phone. I understand that I may revoke my consent at any time by contacting The Raleigh House at 720.891.4657.

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