Private Practice Therapist Application: Adult & Marriage Specialist
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
How did you find out about us?
*
What is your primary licensure or area of expertise?
*
What is your professional license number?
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In what state(s) are you licensed?
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In what year were you initially licensed?
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Are you currently credentialed with any insurance companies?
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Aetna/Cofinity
Blue Cross Blue Shield of Michigan
Blue Care Network HMO/POS
I am not currently credentialed
Other
How many years of experience do you have treating patients in an outpatient psychotherapy setting?
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How many clients would you desire to see per week?
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What are your preferred areas of specialization or interest? (check all that apply).
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Couples/marriage counseling
Family counseling
Adults
Children (Under 11)
Adolescents (11-18)
LGBTQIA+ & Gender
Trauma
Grief & Loss
DBT
EMDR
ERP
Suicide Ideation
Self-harm
Other
Are you currently trained in DBT, EMDR, or ERP?
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Yes
No
Other
If yes, please provide detail.
Are you interested in becoming trained in DBT, EMDR, or ERP?
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I am interested in becoming DBT trained
I am interested in becoming EMDR trained
I am interested in becoming ERP trained
All of the above
I am not interested at this time
Please list any additional specialty practice areas or training beyond the educational requirements for licensure.
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Are there any populations that you're opposed to working with from a moral, safety, or competency point of view?
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Are you looking to transfer clients from another practice?
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Yes
No
Have you or a close family member received services with us in the last 12 months?
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Yes
No
Other
How would you prefer to meet with clients?
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In-person
Virtually
Combination of both
What days and hours are you looking to work?
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Are you willing to work evenings or weekends?
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Yes
No
Other
What are your wage/salary expectations? Please note that hourly rates will depend on caseload, experience, and licensure.
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Are you looking for a part time or full time position?
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Part time
Full time
Do you understand that this is a 1099 position that does not include benefits, with the opportunity to build to a full time position?
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Yes
No
We do not have a non-compete clause and understand that applicants may have multiple jobs while building their practice. Do you intend on working anywhere else during this process?
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Yes
No
Other
What is your expected start date?
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-
Month
-
Day
Year
Date
Do you have interest in providing any of the following services?
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Individual therapy
Group therapy
Supervision of limited licensed clinicians
Leadership roles
Please describe any experience you have in the services listed above:
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How would you describe yourself as a therapist?
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What treatment approaches or theory drives your clinical interventions and why?
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Tell us about your professional goals/ambitions:
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What drew you to our practice and why would you be a good fit?
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Please submit your cover letter.
*
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Please submit your resume.
*
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Please submit at least two work or academic related references.
*
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If you would like to attach a brief video introducing yourself, please upload your attachment here.
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Optional Professional Disclosure Statement (if you have one):
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Submit
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