Private Practice Therapist Application: Child/Teen/Family 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?
*
In what state(s) are you licensed?
*
In what year were you initially licensed?
*
Are you currently credentialed with any insurance companies?
*
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?
*
How many clients would you desire to see per week?
*
What are your preferred areas of specialization or interest? (check all that apply).
*
Couples/marriage counseling
Family counseling
Adults
High-risk children
PANS/PANDAS
Children (Under 11)
Adolescents (11-18)
LGBTQIA+ & Gender
Trauma
Grief & Loss
DBT
EMDR
Suicide Ideation
Self-harm
ERP
Other
Are you currently trained in DBT, EMDR, or ERP?
*
Yes
No
Other
If yes, please provide detail.
Are you interested in becoming trained in DBT, EMDR, or ERP?
*
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.
*
Are there any populations that you're opposed to working with from a moral, safety, or competency point of view?
*
Are you looking to transfer clients from another practice?
*
Yes
No
Have you or a close family member received services with us in the last 12 months?
*
Yes
No
Other
How would you prefer to meet with clients?
*
In-person
Virtually
Combination of both
What days and hours are you looking to work?
*
Are you willing to work evenings or weekends?
*
Yes
No
Other
What are your wage/salary expectations? Please note that hourly rates will depend on caseload, experience, and licensure.
*
Are you looking for a part time or full time position?
*
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?
*
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?
*
Yes
No
Other
What is your expected start date?
*
-
Month
-
Day
Year
Date
Do you have interest in providing any of the following services?
*
Individual therapy
Group therapy
Supervision of limited licensed clinicians
Leadership roles
Please describe any experience you have in the services listed above:
*
What treatment approaches or theory drives your clinical interventions and why?
*
How would you describe yourself as a therapist?
*
Tell us about your professional goals/ambitions:
*
What drew you to our practice, and why would you be a good fit?
*
Please submit your cover letter.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please submit your resume.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please submit at least two work or academic related references.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If you would like to attach a brief video introducing yourself, please upload your attachment here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Optional Professional Disclosure Statement (if you have one):
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: