client distribution request Clinician Name(Required) First Last Clinician Email(Required) Total Current Number of Active Clients (Defined as clients who have been seen in the last 90-days)(Required)Please enter a number from 0 to 100.Actual Number of Clients Seen in Previous Business Week(Required)Please enter a number from 0 to 100.Actual Number of Clients Scheduled in this Business Week(Required)Please enter a number from 0 to 100.Number of Days Seeing Clients per Week(Required)Please enter a number from 0 to 4.Today's Date(Required) MM slash DD slash YYYY Date of Last Client Distribution Request(Required) MM slash DD slash YYYY Number of Clients Dropping Out Since Last Request, Names(Required)Make a list of the names of clients who have dropped out recently.Have you followed up with all clients who have dropped out via email?YesNoIf no, please explain.(Required)Are there any clients that CLT should help you reach out to regarding scheduling? Please list names and email addresses below, one per line.(Required)NOTE: Enter n/a if there are none.To meet the desired weekly average of approximately 23-24, how many additional clients do you suppose are required?(Required)Any additional notes?CAPTCHA Δ
