Provisionally Licensed Clinician ALCS Application

Provisionally Licensed Clinician ALCS Application

Thank you for your interest in joining the Abundant Life Counseling Services team! We look forward to getting to know you.
APPLICANT INFORMATION
Name

First Name Last Name
Gender
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
EMPLOYMENT AND VOLUNTEER EXPERIENCE
Counseling-Related Employment Information

You may also list non-compensated practicum and internship placements here (please specify).
Employer
Position Title
Dates of Employment
Reason for Leaving
Employer Phone Number
Please enter a valid phone number.
Name of Supervisor
Please give a brief description of the place and the types of counseling-related activities and duties you performed during your time working there:
Employer
Position Title
Dates of Employment
Reason for Leaving
Employer Phone Number
Please enter a valid phone number.
Name of Supervisor
Please give a brief description of the place and the types of counseling-related activities and duties you performed during your time working there:
Employer
Position Title
Dates of Employment
Reason for Leaving
Employer Phone Number
Please enter a valid phone number.
Name of Supervisor
Please give a brief description of the place and the types of counseling-related activities and duties you performed during your time working there:
Other Recent Job Experience

Please list any non-counseling-related work experience during the past 3 years.
Employer
Position Title
Dates of Employment
Reason for Leaving
Employer Phone Number
Please enter a valid phone number.
Name of Supervisor
Employer
Position Title
Dates of Employment
Reason for Leaving
Employer Phone Number
Please enter a valid phone number.
Name of Supervisor
Employer
Position Title
Dates of Employment
Reason for Leaving
Employer Phone Number
Please enter a valid phone number.
Name of Supervisor
Volunteer Experience
Organization
Total Hours Served
Role and Responsibilities
Organization
Total Hours Served
Role and Responsibilities
Organization
Total Hours Served
Role and Responsibilities
Organization
Total Hours Served
Role and Responsibilities
Employment and Volunteer Experience Reflection
What have you learned from your employment background and volunteer experience (skills developed, lessons learned, perspectives shaped) that would bring value to ALCS and would assist you in growing a counseling practice?

ACADEMIC, PROFESSIONAL, AND PERSONAL DEVELOPMENT
Undergraduate Education
Undergraduate School
Location of School
Major
Dates Attended
Degree Achieved
BA, BS, etc
Date Graduated
Cumulative GPA
Undergraduate School
Location of School
Major
Dates Attended
Degree Achieved
BA, BS, etc
Date Graduated
Cumulative GPA
Undergraduate School
Location of School
Major
Dates Attended
Degree Achieved
BA, BS, etc
Date Graduated
Cumulative GPA
Graduate School
Graduate School
Location of School
Major/Degree Track
Dates Attended
Degree Achieved
BA, BS, MA etc
Date Graduated
Cumulative GPA
Graduate School
Location of School
Major/Degree Track
Dates Attended
Degree Achieved
BA, BS, MA etc
Date Graduated
Cumulative GPA
Professional Development
Type of license you are pursuing

LPC LMFT LCSW
I have passed the NCE exam

Yes No
If you have not taken the NCE exam, when do you expect to take it?
If applicable, provisional license number (for LPC-Associate/LMFT-Associate/LMSW), date issued, and expiration date
Do you currently possess any licenses or certificates issued by any state? If so, please list the name, license/certificate number(s), and issuing state or organization.
Specialized Training

(CST, EMDR, EFT, RPT, CSAT, etc)
Please list any specialized training or certifications you currently possess:
Please list any specialized training or certifications you are currently pursuing:
Please list any specialized training or certifications you plan to pursue, and when
Academic, Professional, and Personal Development Reflection
How has your counseling coursework, pursuit of specialized training, and / or private therapy contributed to your personal development? How do you continue to nurture your personal growth?

Our team is a group of carefully selected individuals who, collectively, are able to serve the community better because of one another. We have a trusted reputation that has been built over the years because of the investment and quality care of top-notch clinicians. As you consider whether or not you might be a good fit for us and whether we might be a good fit for you, who you are as a person, as a believer, and as a therapist will be important. The following questions will help us both to determine goodness of fit, and give us a basis for further conversation during an interview, should we both determine we would like to take next steps.
Short Response Questions
Why are you interested in working for ALCS? What drew you to us? Why do you think you would be a good fit here?
Faith is the common denominator for all of us here at ALCS. Please help us get to know your faith a bit. What's your story and how did you come to know the Lord? (briefly). How is your faith expressed, and how are you different because of it? Are you involved in a local church? If so, please share briefly about your involvement.
Why do you want to be a therapist?
What does "Christian Counseling" mean to you? What do you believe are the distinctives of Christian Counseling?
How do you see yourself implementing faith / spirituality into the counseling process?
While we at ALCS care about, respect, and grow from one another, working with a team is not always easy. What have you found to be essential in working with a boss? In working with a team? How have you approached conflict in the past with a boss and with peers?
How would those closest to you describe your personality and how you function within a team (if you have taken personality assessments, feel free to use that in describing yourself)?
What type of position are you hoping for? Part-time or full-time? How many hours a week would you like to do therapy? How many days a week? Are you available on weekends or in evenings?

Please list hours of the day you could potentially be available to see clients:

	Morning	Afternoon	Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

How many hours would you like to see clients per week?
How many hours would you plan to be available per week?
What is the target client base you are hoping to grow (children, teens, individual adults, couples)? What presenting problems do you feel most passionate about working with?
Would you be interested in leading a therapy group? If yes, what kind(s) of group(s)?
Please list any employment you plan to continue even if employed by ALCS:
Please list any outside commitments you plan to maintain even if employed by ALCS:
Please list any information you think would be helpful for us to know regarding scheduling:
Benefits of this job include us covering overhead costs and marketing and providing administrative support. We are a well-established practice with consistent referrals to help you build a strong practice. You would have the opportunity to learn from top-notch therapists. Our team has giving hearts and we care about one another, value one another's expertise, and support one another. In this context, what unique gifts and experiences would you bring to our team?
If we determine that you would be a good fit here, but don’t have a position to offer at this time, would you want us to keep your application and resume on hand and contact you in the future when a position becomes available?

Yes No
Is there anything else you would like to add or elaborate upon?
What questions would you like us to address in an interview?
REFERENCES

Thank you for your thoughtful investment into this process. Please list three references we may call, with at least one from the mental health field, should we move forward with an interview.
Name

First Name Last Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First Name Last Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First Name Last Name
Relationship
Phone Number
Please enter a valid phone number.
Thank you for considering ALCS!
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Provisionally Licensed Clinician ALCS Application

APPLICANT INFORMATION

EMPLOYMENT AND VOLUNTEER EXPERIENCE

Counseling-Related Employment Information

Other Recent Job Experience

Volunteer Experience

Employment and Volunteer Experience Reflection

ACADEMIC, PROFESSIONAL, AND PERSONAL DEVELOPMENT

Undergraduate Education

Graduate School

Professional Development

Specialized Training

Academic, Professional, and Personal Development Reflection

Short Response Questions

REFERENCES

Thank you for considering ALCS!