Clinician Update Form

Demographic Information

First Name

Middle Initial(s)

Last Name

Phone Number

For Office Use

Address

Street Address, City, State, Zip Code

Drivers' Licenses Number

Drivers' Licenses Expiration Date

Paperwork

Seed Digging, PLLC Agreement(s) Please fill out and sign the appropriate Agreement(s).

Subcontractor Agreement

This agreement is for clinicians that are ONLY working at the Seed Digging Wellness Center (in-person, telehealth, or both).

TSSP Agreement

This agreement is for clinicians that are ONLY working in the Teacher Support Services Program.

Both

These agreements are for clinicians that are working at the Seed Digging Wellness Center (in-person, telehealth, or both) AND working in the Teacher Support Services Program.

Please note that if you choose to email a copy, it MUST be a PDF.

Work Schedule

Monday

Tuesday

Wednesday

Thursday

Friday

By signing your name and date below you are certify the information you provided on and in connection with this form is true and correct to the best of your knowledge.

Signature

Date

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