Time-Off Request Form

First Name

Last Name

Today's Date

How many days are you requesting off?

Beginning date:

Ending date:

Reason for leave:

I understand that this request is subject to employer's approval (electronically sign below)

Print Name:

Date

Recieved, thanks for submitting!

Hummingbird Counseling Services for Women

710 Denbigh Blvd

Building 6A1

Newport News, VA 23608

Therapist Hours

Monday - Friday, 10:00am - 6:00pm

Saturdays, 10am - 2pm
By Appointment Only

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Phone

Email

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