Sub Contractor Position Interest

Ocean Mist Counseling and Wellness employment survey

Fill the form below accurately indicating your potentials and suitability to job applying for.
Name: *

First Name Last Name
Phone Number: *

Area Code Phone Number
E-mail Address:
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How were you referred to us? *

Walk-In Employee Newspaper Ad Facebook Twitter Craigslist Other (please specify)
Other:
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Our compensation starts at $60.00 per session completed. This is for a full-time employment position.
Job Skills & Training
What clinical experience do you bring to this position?: *
Do you have experience offering Telehealth (phone and/or video) services? Do you have an office space where you are able to offer Telehealth services? *
Do you have computer and high speed internet access at home? *
Do you have a license to practice mental health in the state of Oregon? If yes, what is your license number? *
If you are not currently licensed, Are you currently seeking clinical supervision within this position? *
Are you able to work from our Newport Oregon location? *
Have you ever been investigated and/or reprimanded by your licensing Board? If yes, please explain. *
What makes working with us an appealing opportunity for you? *
What would be your ideal situation in terms of numbers of clients per week, hours of availability, etc? *
What is it about you and your work that would draw clients to you and make them really want to work with YOU specifically? *
Successful work in this practice requires working well independently as well as working well as a team member. What would your current supervisor and colleagues say about your ability to manage your schedule and client-load effectively as well as working as a member of a team? *
Where do you see yourself professionally in the next five years? What would be your dream? *
What client issues and age ranges do you feel most comfortable working with? *
Do you feel comfortable seeing couples and/or families? *
Who is your ideal client? *
Please list any insurance companies on which you are currently paneled. *
If you are currently living out of the state of Oregon, what are your plans in regards to moving to Oregon? *
Please describe how you work with clients who have different culture, beliefs, values, or lifestyles than yourself? *
Training or Certifications:
References

Please list two (2) references that are familiar with your work life.
Reference 1
Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
Years Known: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Reference 2
Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
Years Known: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Should be Empty:

Ocean Mist Counseling and Wellness employment survey