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First and Last Name*

Phone Number*

Email*

Is this a new certification or re-certification?*

Indicate Medical Condition*

On a scale of 0-4: Have you been feeling nervous, anxious, or on edge?*

On a scale of 0-4 : Have you been unable to stop or control your worrying?*

On a scale of 0-4: Have you been worrying too much about different things?*

On a scale of 0-4: Have you had trouble relaxing?*

On a scale of 0-4: Have you been feeling so restless that it is hard to sit still?*

On a scale of 0-4: Have you been easily annoyed or irritable?*

On a scale of 0-4: Have you been feeling afraid, as if something awful may happen?*

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