Therapy Café® Administrative Application rev. 03/2025

Therapy Café® Administrative Application

(Property of Therapy Cafe LLC)
Employment Application
Therapy Café® is an EEO/Affirmative Action Employer committed to excellence through diversity. Employment offers are made on the basis of qualifications and without regard to race, religion, national or ethnic origin, disability, age, veteran status or sexual orientation.

Please attach your resume and complete all questions or your application will be deemed incomplete and may not be considered. Please fill out each box. Applications with missing or invalid job numbers may not be considered for any position.
Name (First, MI, Last)
NPI Number
CAQH ID Number
Social Security Number or TIN
Date of Birth
Mailing Address
City, State, and Zip Code
Email
Telephone (Home)
Format: (000) 000-0000.
Telephone (Cell)
Format: (000) 000-0000.
JOB TYPE
Position of interest
Select the days available to work:
I am seeking
How many hours can you work weekly?
Can you work nights?
Date available to begin

MonthDayYear
Date
ADDITIONAL INFORMATION
I certify that I am a U. S. Citizen, permanent resident, or foreign national with authorization to work in the United States.
Have you ever been employed by this company in the past?
Have you ever received mental health services by this company?
Have you ever been convicted of, or entered a plea of guilty, no contest, or had a withheld judgment to a felony?
Have you ever been investigated, charged, or are currently being investigated with harm, neglect or abuse to a child or adult? If so, what were the results?
Do you have a driver's license?
License number
State of Issuance
Expiration Date

MonthDayYear
Date
Are you related to any current Therapy Café® employee?
If YES, what are their names and their relationship to you?
How did you hear about this employment opportunity at Therapy Café®? Check all that apply
EDUCATION

Rows	Yes	No
High School
GED
College
Trade School

WORK EXPERIENCE
Please list ALL work experience beginning with you most recent job held. Attach additional files if necessary.
Company
Supervisor Name
Hrs/week
Address
Start Date

MonthDayYear
Date
Starting Salary
City, State, and Zip Code
End Date

MonthDayYear
Date
Final Salary
Phone Number
Format: (000) 000-0000.
Your last job title
Reason for leaving
List jobs you held, duties performed, skills used or learned, or promotions you received while working at the company.
May we contact this employer?
Company
Supervisor Name
Hrs/week
Address
Start Date

MonthDayYear
Date
Starting Salary
City, State, and Zip Code
End Date

MonthDayYear
Date
Final Salary
Phone Number
Format: (000) 000-0000.
Your last job title
Reason for leaving
List jobs you held, duties performed, skills used or learned, or promotions you received while working at the company.
May we contact this employer?
REFERENCES
Please include name, phone number, and circumstances of your references. Please include three employer resources and three personal references.
1.
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
2.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
3.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
4.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
5.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
6.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
DISCLOSURE QUESTIONS
8. Are there any charges pending or are you currently charged with or have you ever been indicted or found guilty of a felony, gross misdemeanor, misdemeanor, or other offense?
9. Have you ever been found liable, guilty, or responsible for sexual impropriety or misconduct or sexual harassment with a patient/client, co-worker, or other?
15. Are you currently using alcohol or illegal drugs?
To be considered for a position of interest, the following items must be included in the application package:
File Upload

Cancelof
Applicant Signature
Date

MonthDayYear
Date
OFFICE USE ONLY
Date application received

MonthDayYear
Date
Administrative Director Signature/Date
Clinical Director Signature/Date
Should be Empty:

Therapy Café® Administrative Application

Employment Application

JOB TYPE

ADDITIONAL INFORMATION

EDUCATION

WORK EXPERIENCE

REFERENCES

DISCLOSURE QUESTIONS

OFFICE USE ONLY