LEO Clinic Employment Application
The Latin Enrichment Organization, Inc Phone 860-249-0975 | Fax: 1-833-968-2486 |
Time
Hour Minutes
AM
PM
AM/PM Option
Today's Date
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Current Home Address
Number and Street Name
City
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Desired Hourly Rate
*
Desired hourly or annual salary
Current Place of Employment
Name of Employer
Position
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Previous Place of Employment
Name of Employer
Position
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
What position are you applying for?
Please Select
Clinician
School-Based Clinician
Nurse Practitioner
Nurse
Medical Assistant
Receptionist
Counselor (Bachelors Level)
Bilingual Clinician
Clinical Supervisor
Medical Director
Psychiatrist
Primary Care Doctor
Dentist
Intern
Resident
Available start date:
*
-
Month
-
Day
Year
Date
What is your current employment status?
Employed
Unemployed
Self-Employed
Student
How do you prefer to submit your resume?
Upload File
Provide URL
Upload Resume
*
Upload a File
Drag and drop files here
Choose a file
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of
Driver's License
*
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of
Professional Certification or License (Clinical License, APRN, MD, LPN, etc)
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of
DEA (if applicable)
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of
Diploma or Unofficial Transcript (Recent College Transcript)
*
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of
Completed Pre-Employment Physical and TB within a year
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This will be completed by LEO Clinic Primary Care. Once it is completed provide a copy to your immediate supervisor
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of
Completed DCF/Mandated Reporter Training
*
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Choose a file
Please see link to complete course here: https://www.proprofs.com/training/course/?title=communitymrt2022_6282bfc17cb23
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of
Complete W-4
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N/A if you are an Intern. For Employee's please click on this link, complete and upload here: https://portal.ct.gov/-/media/DRS/Forms/2023/Withholding/CT-W4_1222Fillable.pdf
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of
Completed DCF/CPS Background Check
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Please click here and complete: https://portal.ct.gov/-/media/DCF/Policy/NEW-fillin-Forms/DCF-3031-Authorization-for-DCF-CPS-BGC-CR-only-Rev-7-2022.pdf
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of
Complete State Background Check
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Please click the link here and complete. Interns must pay the $36 and submit to the State: https://portal.ct.gov/-/media/DESPP/reports_and_records/DPS0846CCriminalHistoryRecordRequestFormRev120117pdf.pdf?la=en&hash=EA50398A227AA13333672A334F53FB6B
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of
Complete HIPPA Compliance Training (Screenshot Sore )
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Choose a file
Please click the link here and complete. https://compliancy-group.com/free-hipaa-training/hipaa-training-quiz/
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of
Emergency Contact
Emergency Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Special Instructions:
In the event of a medical emergency, please describe any emergency procedures or restrictions on medicationsof which emergency personnel should be aware:
Physician Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
I have voluntarily provided the above contact information and authorize The Latin EnrichmentOrganization and its representatives to contact any of the above individuals on my behalf in the event ofan emergency. Signature
*
Date
*
-
Month
-
Day
Year
Date
I acknowledge that I have read in full and fully understand the above expectations, policies, andprocedures that I have received during my initial orientation. Signature
*
Date
*
-
Month
-
Day
Year
Date
*
Direct Deposit Account Information
*
Routing Number
Account Number
Bank Name
*
*
Voided Check or Bank Letter
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N/A for Interns
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of
Primary Care Outpatient Providers
*
Rows
Requested
Approved Request
Decline Request
N/A
Management of Routine Pediatric Care 12 yr under
Management of Routine Adolescent Care
Management of Routine Adult Care
Management of Routine Prenatal Care
Management of Routine Geriatric Care
Supervision of Residents & Students
Cardiopulmonary resuscitation (BLS)
Initial evaluation of musculoskeletal problems
Suturing of simple lacerations (one layer)
Use of local anesthics for wound repair
Superficial Nerve Block
Debridement, skin or subcutaneous, tissue
Treatment uncomplicated dermatological conditions
Needle aspiration of subcutaneous lesion
Treatment of planter warts
Dressing/Debridement, burn
Lacerations, infected
Suturing of simple 2 layer lacerations
Special competency based on appropriate experience, training,
credentials, or documentation
I am requesting the approve privileges: Signature
Behavioral Health Providers
*
Rows
Requested
Approved Request
Decline Request
N/A
Initial Psychiatric Evaluation-Intake
Initial Substance Abuse Evaluation
Treatment Planning
Psychotherapy (Individual)
Psychotherapy (Family)
Psychotherapy (Group)
Treatment of Dual Diagnoses
Couples Therapy/Family Therapy
Psychopharmacology (DR or APRN Only)
Genetic Psychiatry/Counseling
Cognitive Behavior Therapy
Behavioral Health Consultation
Provide Service for Pediatric Patients (newborn to 1
year)
Provide Service for Adolescents (13-19 years of age)
Provide Service for Pediatric Patients (1 year thru 12
years)
Behavioral In-Home Therapy
Psychiatric Medication Management (DR or APRN
Only)
P
Autism Treatment
Suicide and Homicide Counseling
Eating Disorder Treatment
I am requesting the approve privileges:
Continue
Continue
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