CROSSPOINT CLINICAL SERVICES APPLICATION FOR EMPLOYMENT

CROSSPOINT CLINICAL SERVICES APPLICATION FOR EMPLOYMENT
CrossPoint Clinical Services is an equal opportunity employer. CrossPoint Clinical does not discriminate in employment with regard to race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service or any other characteristic protected by law.
OUR MISSION

Our mission is to promote personal healing through quality psychotherapeutic services and guide others to do the same with our professional consultation services. Our services are based on sound clinical practice and biblical principles. We believe that trust, respect, confidentiality and compassion are essential to our work with individuals, families, and professional clients. Our aim is to provide services regardless of a person’s ability to pay.
CONTACT US

Administrative Offices

117 Park St., Suite 201A

West Springfield, MA 01089

www.crosspointclinical.org
PERSONAL INFORMATION

Incomplete information could disqualify you from further consideration. Please complete all fields.
Name

First Name Last Name
Date

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number (Home)
Please enter a valid phone number.
Phone Number (Mobile)
Please enter a valid phone number.
Are you eligible to work in the U.S?

Yes No
Are you at least 18 years or older? (If no, you may be required to provide authorization to work.)

Yes No
Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?

Yes No
EMPLOYMENT DESIRED
Date you can start?

Month Day Year
Date
Hourly rate/Salary desired?
Position desired?
Are you currently employed?

Yes No
If currently employed, may we inquire of your present employer?
REFERRAL SOURCE
How did you hear about us?
Have you ever worked for CrossPoint Clinical Services?

Yes No
If yes to previous question, please explain.
Were you referred by someone who works for CrossPoint Clinical Services?

Yes No
If yes, who?
Please enter the name of the CrossPoint Services who referred you
EDUCATION
Name of High School?
Location of High School?
City/Town and State
Degree Received?
Subjects studied/Major?
College or University?
Location of College or University?
City/Town and State
Degree Received?
Subjects studied/Major?
Name of Graduate School/Other Institution?
Location of Graduate School/Other Institution?
City/Town and State
Degree Received?
Subjects studied/Major?
PROFFESIONAL SKILLS
Please list any professional licenses, certifications, or registrations:
EMPLOYMENT HISTORY

Include your last seven (7) years of employment history, including periods of unemployment, starting with the most recent and working backwards in time. Incomplete information could disqualify you from further consideration.
Employer Name #1
Employed From:

Month Day Year
Date
Employed To:

Month Day Year
Date
Employer #1 Phone Number
Please enter a valid phone number.
Employer #1 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job Title
Immediate Supervisor and Title
Summarize the nature of work performed and job responsibilities
Reason for leaving?
Employer Name #2
Employed From:

Month Day Year
Date
Employed To:

Month Day Year
Date
Employer #2 Phone Number
Please enter a valid phone number.
Employer #2 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job Title
Immediate Supervisor and Title
Summarize the nature of work performed and job responsibilities
Reason for leaving?
Employer Name #3
Employer From

Month Day Year
Date
Employed To

Month Day Year
Date
Employer #3 Phone Number
Please enter a valid phone number.
Employer #3 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job Title
Immediate Supervisor and Title
Summarize the nature of work performed and job responsibilities
Reason for leaving?
Employer Name #4
Employer From

Month Day Year
Date
Employer To

Month Day Year
Date
Employer #4 Phone Number
Please enter a valid phone number.
Employer #4 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job Title
Immediate Supervisor and Title
Summarize the nature of work performed and job responsibilities
Reason for leaving?
REFERENCES

Give the names of three professional references not related to you, whom you have known at least three (1) year.
Name of Reference #1

First Name Last Name
Address of Reference #1

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number of Reference #1
Please enter a valid phone number.
Email of Reference #1
example@example.com
Company of Reference #1
Years Acquainted with Reference #1
Name of Reference #2

First Name Last Name
Address of Reference #2

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number of Reference #2
Please enter a valid phone number.
Email of Reference #2
example@example.com
Company of Reference #2
Years Acquainted with Reference #2
Name of Reference #3

First Name Last Name
Address of Reference #3

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number of Reference #3
Please enter a valid phone number.
Email of Reference #3
example@example.com
Company of Reference #3
Years Acquainted with Reference #3
Please read carefully before signing.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for CrossPoint Clinical Services to hire me. If I am hired, I understand that either CrossPoint Clinical or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of CrossPoint Clinical has the authority to make any assurance to the contrary.

I attest with my signature below that I have given to CrossPoint Clinical true and complete information on this application. No requested information has been concealed. I authorize CrossPoint Clinical to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.
Signature

Clear
Date of Signature

Month Day Year
Date
THIS APPLICATION IS VALID ONLY FOR 60 DAYS FROM THE DATE ABOVE.
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