Student Mentoring

Preceptor Request Form

Apply for student precepting and clinical rotations with Blissz Psychiatry & Healthcare LLC — hands-on clinical experience guided by a Board Certified Psychiatric Mental Health Nurse Practitioner.

$10 / Hour

Simple hourly rate for student precepting and clinical rotation services.

$200 Deposit

A refundable commitment deposit is required. Payment details are sent after we review your application.

Have Questions?

Reach our office anytime at
admin@blisszpsychiatry.com

Student's Information

Complete the form below and our office will get back to you shortly. Once we receive your application, we will reply with payment information — your application will not be processed until your payment is received.

Please do not include personal or private health information. Information submitted through this form is forwarded to our office by email, not via a secure messaging system, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted.

First Name

Middle Name

Last Name

Today's Date (MM/DD/YYYY)

Phone Number

Address (Street, City, State, ZIP)

Institution Name

Program / Specialty

Course Name

Hours Required

Rotation Start Date (MM/DD/YYYY)

Rotation End Date (MM/DD/YYYY)

How many terms do you plan to complete with the clinic?

Resume/CV Link (Google Drive, Dropbox, etc.)

Support Link

Your Signature (type your full name)

Do you have anything to share with us?

Terms & ConditionsTerms & ConditionsI accept the terms & conditions. I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.

15 + 7 =

Preceptor Request Form

$10 / Hour

$200 Deposit

Have Questions?

Student's Information

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