This government document is issued by Behavior Health Executive Council (BHEC) for use in Texas
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https://www.google.com/url?client=internal-element-cse&cx=d5b2ca28d35951e51&q=https://www.bhec.texas.gov/wp-content/uploads/2020/09/Exam-Request-Form-2020Sept.pdf&sa=U&ved=2ahUKEwjmi5-ww6GJAxWT3wIHHSyqHZA4ChAWegQICRAB&usg=AOvVaw1Brv7XLNASGX_6FGD3NkWY&fexp=72781342,72781340,72781341