Application to Provide Forensic Evaluations for Asylum Seekers
Forensic Evaluations can be completed by licensed physicians, licensed mental health professionals, licensed nurse practitioners and licensed physician assistants
Date of Application
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Month
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Day
Year
Date
Which best describes you:
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I am a medical professional wishing to complete forensic medical evaluations
I am a mental health professional wishing to complete forensic psychological evaluations
Personal Information
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Professional Information
Professional Degree
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Date Received
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Month
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Day
Year
Date
Institution received from or attending
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License Type
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License Number
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Date License Received
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Month
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Day
Year
Date
Languages Spoken
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Work with
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Children
Adolescents
Adults
Families
Specialty area(s) of care
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Additional Certifications and credentials
How did you learn about Survivors of Torture, International (SURVIVORS)?
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Why are you interested in participating in the SURVIVORS’ Partnership Network?
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Please explain your interest and experience in working with trauma survivors or populations impacted by immigration.
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Required Documents
Please attach the following required documents.
Your Professional CV/Resume
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A copy of your current license
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Survivors of Torture, International is an Equal Opportunity Employer
SURVIVORS prohibits discrimination against employees, applicants for employment, individuals providing services in the workplace pursuant to a contract, unpaid interns, or volunteers based on any legally-recognized basis, including, but not limited to, their actual or perceived race, color, religion, religious creed, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information, marital status, sex (including pregnancy, childbirth, breastfeeding, or related medical conditions), gender, gender identity, gender expression, age, sexual orientation, veteran and/or military status, protected medical leaves (requested or approved for leave under the Family and Medical Leave Act or the California Family Rights Act), political affiliation, domestic violence victim status, immigration status or any other status protected by state or federal law.”
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