Clinician Formal Request Form

Please use this form when you are asking the practice to review or approve a specific change, exception, additional support, resource, or practice-level decision. This may include requests related to workload, scheduling expectations, compensation, policies, workflows, training, technology, or other practice operations.

This form is not for routine questions about existing processes, such as billing, scheduling, booking, or finding a resource. Please send these questions through the Main Email or your PM Spruce thread.

Practice Management will review the information provided, consider the possible impact of the request, and contact you if additional information is needed. Please allow up to 30 days for the initial review. Submitting this form does not mean that the request has been approved. Please continue following the current process until you receive a final decision from Practice Management.

If your concern involves an immediate client safety, legal, privacy, compliance, or urgent operational matter, please contact Practice Management directly instead of waiting for the form review process.

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Name *

First

Last

Email *

Which area is your request related to? *

• Clinical Operations
• Client Scheduling or Coordination
• Clinician Scheduling or Workload
• Practice Policy or Procedure
• Training or Professional Resources
• Office, Equipment, or Supplies
• Marketing or Clinician Profiles
• Other

If other… *

Please identify who may be affected by the request *

• The clinician submitting the request
• A client or multiple clients
• Other clinicians
• Supervisors or consultation groups
• Practice Management
• The full practice
• Other individuals or groups
• Other

If other… *

Please describe your request. *

Please describe the current process or situation related to your request. *

How is the current situation affecting your work, clients, or practice operations? *

Are there any client safety, clinical, ethical, legal, privacy, or compliance concerns related to this request? *

work, Which help

Would this request require any additional resources? *

Is there a possible solution or option you would like Practice Management to consider? *

Why is this solution or option needed? *

Is there a preferred timeframe or deadline for this request or solution? *

Have you previously discussed this matter with Practice Management? *

Is there anything else Practice Management should consider when reviewing this request? *

Please upload any documents that may help us review your request.

Drag & Drop Files, Choose Files to Upload

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