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Search for:
Home
About
Locations
Our Philosophy
FAQ
What We Offer
Therapy and Counseling
Life and Career Coaching
Fitness Coaching
Nutrition and Wellness Coaching
Yoga, Meditation, and Mindfulness
Groups
Virtual Therapy and Telehealth
Wellness Professionals
Revive Online
Blog
Newsletter
Shop
FREE Consultation
Home
About
Locations
Our Philosophy
FAQ
What We Offer
Therapy and Counseling
Life and Career Coaching
Fitness Coaching
Nutrition and Wellness Coaching
Yoga, Meditation, and Mindfulness
Groups
Virtual Therapy and Telehealth
Wellness Professionals
Revive Online
Blog
Newsletter
Shop
FREE Consultation
Staff Form – Clinician Availability
Chris Obara
2021-08-06T20:28:47+00:00
Clinician Availability
Clinician Availability
Clinician's with scheduling requests, case-load requests, or changes in preferences should complete the following form. This information will be sent to Intake and Admin so that it can be incorporated into future client assignments.
If you re requesting a change in schedule, Admin will reach out to discuss your requested schedule.
Clinician Name
*
Requested Effective Date
*
Changes being made
Schedule
Referral Needs
Referral Preferences
REFERRAL NEEDS
# Referrals Requested
Preference Details
Additional Details
REFERAL PREFERENCES, RESTRICTIONS, & LIMITATIONS
Families
Yes
No
Couples
Yes
No
Children
Yes
No
Males
Yes
No
Additional Details
SCHEDULE REQUESTS
DAYS
Monday
LOCATION
CT - Stamford
CT - Norwalk
FL - Miami
Virtual
TIMES
Tuesday
CT - Stamford
CT - Norwalk
FL - Miami
Virtual
Wednesday
CT - Stamford
CT - Norwalk
FL - Miami
Virtual
Thursday
CT - Stamford
CT - Norwalk
FL - Miami
Virtual
Friday
CT - Stamford
CT - Norwalk
FL - Miami
Virtual
Saturday
CT - Stamford
CT - Norwalk
FL - Miami
Virtual
Sunday
CT - Stamford
CT - Norwalk
FL - Miami
Virtual
Please provide any additional comments & information
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