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 admin@blisszpsychiatry.com

Student's Information

Clinical Rotation Details

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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