24/7 Crisis Line
(800) 992-1716

Client Portal Access Request

Prefix:


First Name:


Last Name:


Address:


SSN (last 4 digits):


Primary Phone:


City:


State:


Zip:


Email:


DOB:


Pimary Clinic and provider at Woodland Centers:


Terms and Condition:
  • I understand Client Portal is intended as a secure on line source of confidential information. If I share my user ID and password with another person, that person may be able to view my information. Be sure the email address is confidential and secure and can only be viewed by you.
  • I understand that use of Client Portal is entirely voluntary and I am not required to use Client Portal.
  • I understand that this consent will remain in effect until I provide Woodland Centers with a written request for revocation.
  • I hereby affirm that I am the client identified above. I understand that I may be subject to penalties by law for submitting false or misleading information related to this application for Client Portal.
  • I understand the information I provide on this form is used only to confirm my identity. Updates to this information will not be made in my medical record
  • By clicking submit below, I acknowledge that I have read and understand this and the Client Portal Terms and Conditions and I agree to its Terms.

We will email your activation code to the email address after validating your submission with your Woodland Centers Health Record information. Should we have any questions we will contact you via the email you have submitted.

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