E-QPASS Account and Moderator Registration Form

Welcome
Thank you for your interest in a FREE trial of the newest release of e-QPASS, the electronic version of the original Quick Psycho Affective Symptoms Scan.

Focused Future is passionate about adding evidenced based information to your comprehensive treatment plans to further advance your client therapeutic engagement and as a support structure to enhance your client outcomes. e-QPASS will do that!

Please enter the required information in the form provided below and click the SUBMIT button to get started today.

What to expect
Once you submit your registration you will be receiving two (2) emails. The first email your Login web address (Bookmark) for ongoing access, as well as your Username. The second email will contain your Password. Emails are sent individually for your safety and security purposes.

Practice Information

Practice Name:

Practice Category:

Practice Type:

NOTE: Free trials are currently only available for Solo Practices. if you would like to try four (4) free assessment, please enter your information as a Solo Practice and you can have your profile updated when you decide to subscribe. If you have any questions or concerns, please contact Focused Future.

Practice Mailing Address:

City

State

Zip Code

Primary Contact

First Name:

Middle Name:

Last Name:

Credentials:

Phone No.:

Cell No.:

Email:

Website:

CURRENT OFFERS / DESCRIPTION:

After completing the four (4) FREE E-QPASS Assessments, a special subscription price will be offered.

Amount Due:

Verification

I agree that I am fully responsible and knowledgeable to protect all my clients PHI and HIPAA related information. Focused Future LLC is not responsible for PHI or HIPAA related information once it is downloaded from the e-QPASS server.

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Electronic Quick Psycho Affective Symptoms Scan

E-QPASS Account and Moderator Registration Form