Clinical Internship Placement Request

    If you would like to schedule a clinical with RehabCare, please fill out the form below.

    School Name:

    Coordinator Name and Contact Information:
    Name:
    Phone Number:
    Email Address:

    Current Contract with RehabCare/Kindred:

    YN

    Student Discipline:



    Other Discipline:

    Level:

    Goals:

    Setting:



    Other Setting:

    Start Date:

    End Date:

    Locations (City / State):

    Comment:

    * Please remember to submit a Certificate of Compliance Form if you have not already.