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Clinic Scheduling Form

This form is intended for licensed and student clinicians to submit their clinic schedule to Murney Clinic reception. Instructions:
  1. This form should be completed at least two full weeks before the schedule begins in order to maximum our opportunity to serve our clients.
  2. Use CONTROL + CLICK to select more than one time in the Intake time fields.
  3. If you need to indicate that an intake time slot(s) have been filled, please use the Intake Slot Filled form.
  4. Use the comment field to indicate days you will be gone or any exceptions during the schedule.
  5. A licensed provider should choose the last option under Supervisor, private practice clinician.
  6. This form should NOT be used to convey any client information.
Required entries are indicated with an asterisk (*) in the field name.