Name
*
First Name
Last Name
Pronouns
Phone
*
Email
Position
Please Select
Child/Teen Therapist (Long Island, NY)
Child/Teen Therapist (Denver, CO)
Adult Therapist (Denver, CO)
Do you have an active license?
Please Select
No
Yes, New York
Yes, Colorado
Yes, Both New York and Colorado
Yes, In another state not listed
What Shifts are you willing to work?
Week Days
Week Evenings
Saturdays
Ages you work with
Children Under 5
Children 5 - 10
Children 10 - 14
Adolescents 14-17
Adults 18-65
Seniors 65+
Please list any specializations, including modalities and populations you work with
Please list the insurances with which you are already credentialed
None
Aetna
BCBS
Kaiser
United Healthcare
Cigna
GHI Emblem Health
Other
Cover Letter
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CV
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Professional Reference 1
Please provide 3 references from supervisors, managers, employers, etc. Do not include references from peers, friends, or co-workers. We will proceed with checking benefits if we schedule an interview with you. If, for any reason, you do not want your references contacted, then please do not list them as a reference.
Name
*
First Name
Last Name
Phone
*
Email
Professional relationship
Professional Reference 2
Please provide 3 references from supervisors, managers, employers, etc. Do not include references from peers, friends, or co-workers. We will proceed with checking benefits if we schedule an interview with you. If, for any reason, you do not want your references contacted, then please do not list them as a reference.
Name
*
First Name
Last Name
Phone
*
Email
Professional relationship
Professional Reference 3
Please provide 3 references from supervisors, managers, employers, etc. Do not include references from peers, friends, or co-workers. We will proceed with checking benefits if we schedule an interview with you. If, for any reason, you do not want your references contacted, then please do not list them as a reference.
Name
*
First Name
Last Name
Phone
*
Email
Professional relationship
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