Student Mentoring | Blissz Psychiatry LLC

PRECEPTOR REQUEST FORM

Student Precepting and Clinical Rotation services are provided at a $10 hourly rate. A refundable Commitment Deposit of $200 will be charged on the next page upon completing this form.
Be sure not to include personal and private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.
For questions, please contact the office at [email protected]

Student's Information

First Name

Middle Name

Last Name

Birthday

Phone

Street Address

City

Region/State/Province

Postal/Zip Code

Country

Clinical Rotation Details

Institution Name

Program/Specialty

Course Name

Hours Required

Start Date

End Date

Upload Your Resume/CV

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

Support Link

Do you have anything to share with us?

I accept 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.

Your Signature

Review your application form before submitting. Once we recieve your application, we will reply you with our payment information.
Your application will not be processed until your payment is recieved.

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