Mind Therapy Clinic (MTC) requires at lease two (2) weeks notice to process Leave of Absence request.  If the request is not received at a minimum two (2) weeks or fourteen (14 days) prior to the date of absence, the leave of absence request will be denied.  Mind Therapy Clinic does not excuse absences of less than one (1) week or seven (7) days of treatment.  Patients are financially responsible for all unexcused absences.


I have read, understand, and agree to the terms of this Leave of Absence Request submitted to Mind Therapy Clinic.

Name *
Name
Request Submission Date
Request Submission Date
Leave of Absence Starting Date
Leave of Absence Starting Date
Leave of Absence End Date
Leave of Absence End Date
Signed Date
Signed Date