Identity Verification

We've Moved!

We’ve updated things a bit, and this form is no longer in use. You can find the new version here.
Are you a Provider or Client of Grow Therapy?
Is this a MFA (Multi-Factor Authentication) related lockout?*

YesNo
Did the SMS verification code arrive on your phone?*

YesNo
Can you access your backup recovery code?*

YesNo
Have you attempted to sign in using all authentication methods on your account?*

YesNo
Please enter any further context on issues you might have experienced:
Name as it appears on your ID*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
Please use the email you entered when creating your account.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Last Appointment (If you have not had your first session yet, please input the date of your upcoming first session instead)*

MonthDayYear
Date
Name of Client Seen in Last Appointment*

First NameLast Name
Name of Provider Seen in Last Appointment*

First NameLast Name
Last 4 Digits of Credit Card*
CAQH ID*
Please upload an image of a government-issued identity document:*

Cancelof
Please enter any other context you would like to provide:
Should be Empty: