Be Well Moms Family Center
Employment Application - Join our Amazing Team !!!
Full Name
First Name
Last Name
E-mail
example@example.com
What position are you applying for?
Please Select
Psychotherapist Fully Licensed Master or PHD Level
Psychotherapist Limited Licensed Master Level
Re-unification Therapist Bachelors Degree
Re-unification Assistant Associates Degree
Internship
Practicum Student
Case Manager
Family Re-unification Specialist
Intake Clerk/Scheduler
Administrative Coordinator
Billing Specialist
Massage Therapist
Yoga Therapist
Marketing Coordinator
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 Here
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Please upload a copy of your credentials (Degree, Certifications, Liability Insurance, License). Please provide clear copies.
Upload File
Provide URL
Upload Here (You may add more than one file)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Back
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Last 4 Digits of your SSN
Professional License Number
NPI Number
CAQH Number
Other Credential Type and Number
Please select insurance companies you are in network with (To your knowledge)
*
Blue Cross and Blue Shield
Blue Care Network
CIGNA
United Health Care / UBH Commercial
United Health Care Medicaid
Medicaid - CHAMPS Enrolled
Meridian Medicaid
Priority Health
Blue Cross Complete Medicaid
Other
I am not enrolled with any health care networks at this time
Please select no more than 6 areas you consider yourself proficient
*
Anxiety and Deppression
Post Partum Depression
Infertility Issues
Bipolar
Schizophrenia
Marital or Couples
Domestic Violence
Anger Management
Trauma
Re-unification Therapy
Family systems
Court Ordered
Parenting Classes
Incarcerated Individuals
Grief and Loss
Eating Disorders
Social Media Addiction
Substance Use Disorder
Children
Geriatric Population (Seniors)
Teens and Adolescents
Veterans
Ethnicity (We ask this question to assist clients with preference) This is an equal employment opportunity and we do not discriminate due to race, color, religion, gender, sex, disability nor familial status.
Please Select
Black
White
Hispanic
Chinese
Indian
Asian
Nigerian
Mexican
Other
Gender (We ask this question to assist clients with preference) This is an equal employment opportunity and we do not discriminate due to race, color, religion, gender, sex, disability nor familial status.
Please Select
Male
Female
Transgender
Other
Have you ever had any legal convictions, felonies, misdemeanors or pending criminal charges against you or your license at any time?
*
Please Select
Yes
No
If the answer is yes, that does not necessarily bar you from employment. We consider the nature of the offense, time of its occurrence and other factors.
Are you willing to under go a background check and drug screening once an offer has been made and given that you accept the offer of employment.
*
Please Select
Yes
No
If the screening is positive that does not necessarily bar you from an opportunity of employment. We do consider factors such as prescription drugs and other factors.
Do you grant this organization and its administrative affiliates permission to check your references?
*
Please Select
Yes
No
Reference #1 (Must be a current or previous Supervisor)
*
First Name
Last Name
Reference #1 E-mail
*
example@example.com
Refernece #1 Phone Number
*
Reference #2 (Must be anyone except family)
*
First Name
Last Name
Reference #2 E-mail
*
example@example.com
Refernece #2 Phone Number
*
Please list 3 to 5 words that you feel people would use to describe strengths of your personality and or character.
*
Limit to 3 to 5 words
Please list 3 to 5 words that you feel people would use to describe weaknesses of your personality and or character.
*
Limit to 3 to 5 words
In a scenario, where a client was either always late to appointments, constantly rescheduling, or requesting to end sessions early, How would you best handle the situation.
*
Please limit your response to 250 Characters.
Emergency Contact Name and Phone number
Print your Full Name (First and Last)
Date
Signature
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