STUDENT | Elle Cliniques HTC

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 Info@ellecliniques.com.

Student's Information

First name

Birthday

Middle Initial

Last name

Street Address

Postal / Zip code

City

Region/State/Province

Clinical Rotation Details:

Institution Name

Hours Required

Upload your Resume/CV

Upload File

Program/Specialty

Sart Date

How many Terms do you plan to complete with the clinic

Course Name

End Date

Supporting 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

Today's Date

Elle Cliniques HTC

(Access To Holistic Care)

Mental Health, Psychiatry & Wellness Clinic

Preceptor Request Form

Student's Information

Clinical Rotation Details:

Wait for the payment page after you hit the submission button.
Your application will not be processed until your payment is received.

Preceptor Request Form

Student's Information

Clinical Rotation Details:

Wait for the payment page after you hit the submission button. Your application will not be processed until your payment is received.

Wait for the payment page after you hit the submission button.
Your application will not be processed until your payment is received.