Growth and Empowerment Employment Application

Welcome to Growth & Empowerment Mental Healthcare Services, LLC!

We want to personally thank you for your interest in joining the Growth & Empowerment Mental Healthcare Services (G&E MHS) team. We are excited to have you begin the onboarding process.

Please fully complete the application in its entirety. If you have any questions or need assistance with the forms, feel free to reach out to us at hr@growthempowermentmhs.com. If you do not have time to complete the entire application, you can save your progress and return to the form at a later time to complete your submission. Click SAVE, and you will receive a link via email to pick up right where you left off.

Once again, thank you for your interest in joining Growth & Empowerment MHS. We will be in touch with you!

Please answer Yes or No for each question.

Rows	YES	NO
Are you a High School Graduate?
High School Equivalency?
Are you presently attending school?

High School/HS Equivalency*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Graduation Date

MonthDayYear
Date
Type of Education
Name of Institution:
Field of Study
Degree
Did you attend an accredited program?
Other Degree or Certificate
YesNo
Graduation Date

MonthDayYear
Date
Type of Education
Name of Institution:
Field of Study
Degree
Did you attend an accredited program?
Other Degree or Certificate
YesNo
Graduation Date

MonthDayYear
Date

Name of License/Certificate
License or Certificate Number
Are you Dependent or Independently Licensed? If Dependent, please list your Clinical Supervisor's Contact Information.
Date Issued

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Name of License/Certificate
License or Certificate Number
Are you Dependent or Independtly Licensed? If Dependent, please list your Clinical Supervisor's Contact Information.
Date Issued

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Name of License/Certificate
License or Certificate Number
Are you Dependent or Independtly Licensed? If Dependent, please list your Clinical Supervisor's Contact Information.
Date Issued

MonthDayYear
Date
Expiration Date

MonthDayYear
Date

Please list three (3) professional references.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Relationship
Supervisor, Peer, Mentor, i.e.
Company Name & Title
Ex.: Timothy Wise, Director of Strategic Planning
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Relationship
Supervisor, Peer, Mentor, i.e.
Company Name & Title
Ex.: Timothy Wise, Director of Strategic Planning
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Relationship
Supervisor, Peer, Mentor, i.e.
Company Name & Title
Ex.: Timothy Wise, Director of Strategic Planning

Please attach all the quality documents in DOC., PDF, or JPEG format. The limit per file is 500 KB.

Required documents:
- Resume or CV
- Cover Letter
Resume/CV*

Upload a File

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Cover Letter

Upload a File

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Applicant's Statement and Authorization to Release Information

(Required for ALL Positions)

I acknowledge that this employment application and any other documents from Growth & Empowerment MHS are not contracts of employment and that any person hired may be terminated by the employer at any time for any reason. I understand that any oral or written statements to the contrary are expressly disavowed and should not be relied upon by any prospective or existing employee. I understand that Growth & Empowerment MHS may modify, change, or revoke any of its employment policies, pay practices, and benefits without my agreement. I hereby state that all answers on this application are true and understand that falsifying this information can lead to termination if hired.
Signature

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Applicant's Certification of Truthfulness

I hereby certify that all the information provided on this application is true and accurate. I understand that providing false or misleading information may lead to the rejection of my application, or if employment has already started, immediate termination. I give my consent to Growth and Empowerment MHS to contact my former employers and educational institutions for verification purposes. I also authorize Growth and Empowerment MHS and its representatives to conduct a comprehensive background check, including the generation of a consumer report, for employment purposes. I understand that the Consumer Report may include verification of my social security number, current and previous addresses, employment history, educational background, character references, drug testing, civil and criminal history records from any relevant agencies, driving records, birth records, and any other public records.
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Tuberculosis Acceptance/Declination
I, (type name) blanks, understand that due to my occupational exposure to potentially infectious materials, I may be at risk for Tuberculosis. I can receive the TB test and/or x-ray at no cost to me.
YesNo
SIGNATURE

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Date

MonthDayYear
Date
YesNo
SIGNATURE

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Date

MonthDayYear
Date

Hepatitis B Acceptance/Declination
Vaccine Acceptance

Hepatitis B virus typically causes clinical illnesses with jaundice; it may also produce a subclinical infection. In either case, complications can occur, including the persistence of infection, chronic carrier state, cirrhosis, and liver cancer. Hepatitis B virus is transmitted principally through contaminated body fluids (especially blood) skin or mucosa; therefore, the likelihood of contracting the disease is greater for individuals (e.g., nurses, direct care workers, and athletic trainers) coming in frequent contact with blood or blood products. I understand that Growth & Empowerment Mental Healthcare Services will reimburse me for the cost of the vaccine once I provide receipts.
Signature

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Vaccine Declination
I have received information from Growth & Empowerment Mental Healthcare Services about the Hepatitis B vaccine. I understand that due to any occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring a Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine, at no charge to me. However, I declined the Hepatitis B vaccine at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
Signature

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DRUG-FREE WORKPLACE POLICY
Growth & Empowerment Mental Healthcare Services intends to help provide a safe and drug-free work environment for our clients and our employees. With this goal in mind and because of the serious drug abuse problem in today's workplace, we are establishing the following policy for existing and future employees of Growth & Empowerment MHS ("Company").

The Company explicitly prohibits:
- The use, possession, solicitation for, or sale of narcotics or other illegal drugs, alcohol, or prescription medication without a prescription on Company or customer premises or while performing an assignment.
- Being impaired or under the influence of legal or illegal drugs or alcohol away from the Company or customer premises if such impairment or influence adversely affects the employee's work performance, the safety of the employee, or others, or puts at risk the Company's reputation.
- Possession, use, solicitation for, or sale of legal or illegal drugs or alcohol away from the Company or customer premises, if such activity or involvement adversely affects the employee's work performance, the safety of the employee, or others, or puts at risk the Company's reputation.
- The presence of any detectable amount of prohibited substances in the employee's system while at work, while on the premises of the company or its customers, or while on company business. "Prohibited substances" include illegal drugs, alcohol, or prescription drugs not taken in accordance with a prescription given to the employee.
The Company will conduct drug and/or alcohol testing under any of the following circumstances:
- RANDOM TESTING: Employees may be selected at random for drug and/or alcohol testing at any interval determined by the Company.
- FOR-CAUSE TESTING: The Company may ask an employee to submit to a drug and/or alcohol test at any time it feels that the employee may be under the influence of drugs or alcohol, including, but not limited to, the following circumstances: evidence of drugs or alcohol on or about the employee's person or in the employee's vicinity, unusual conduct on the employee's part that suggests impairment or influence of drugs or alcohol, negative performance patterns, or excessive and unexplained absenteeism or tardiness.
- POST-ACCIDENT TESTING: Any employee involved in an on-the-job accident or injury under circumstances that suggest possible use or influence of drugs or alcohol in the accident or injury event may be asked to submit to a drug and/or alcohol test. "Involved in an on-the-job accident or injury" means not only the one who was or could have been injured but also any employee who potentially contributed to the accident or injury event in any way.
If an employee is tested for drugs or alcohol outside of the employment context and the results indicate a violation of this policy, or if an employee refuses a request to submit to testing under this policy, the employee may be subject to appropriate disciplinary action, up to and possibly including discharge from employment. In such a case, the employee will be given an opportunity to explain the circumstances before any final employment action becomes effective.
DRUG AND/OR ALCOHOL TESTING CONSENT FORM

EMPLOYEE AGREEMENT AND CONSENT TO DRUG AND/OR ALCOHOL TESTING
I hereby agree upon a request made under the drug/alcohol testing policy of Growth & Empowerment Mental Healthcare Services ("Company") to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under company policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. I further authorize and give full permission to have the Company and/or its company physician send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to the Company and/or to any governmental entity involved in a legal proceeding or investigation connected with the test. Finally, I authorize the Company to disclose any documentation relating to such a test to any governmental entity involved in a legal proceeding or investigation connected with the test.

I understand that only duly-authorized Company officers, employees, and agents will have access to information furnished or obtained in connection with the test; that they will maintain and protect the confidentiality of such information to the greatest extent possible; and that they will share such information only to the extent necessary to make employment decisions and to respond to inquiries or notices from government entities.

I will hold harmless the Company, its company physician, and any testing laboratory the Company might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse job action that might arise as a result of the drug or alcohol test, even if a Company or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless the Company, its company physician, and any testing laboratory the Company might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is within the scope of this policy and the procedures as explained in the paragraph above.

This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered.

I understand that the company will require a drug screen and/or alcohol test under this policy whenever I am involved in an on-the-job accident or injury under circumstances that suggest possible involvement or influence of drugs or alcohol in the accident or injury event, and I agree to submit to any such test.
Background Check Authorization

EMPLOYEE AGREEMENT AND CONSENT TO A BACKGROUND CHECK
As part of our hiring process, Growth & Empowerment Mental Healthcare Services, LLC partners with HireRight to conduct background checks on prospective employees. By submitting this application, you acknowledge and agree to the following:

Acknowledgment and Consent
1. I understand that a background check will be conducted as part of the hiring process.
2. I consent to Growth & Empowerment Mental Healthcare Services, LLC and its authorized vendor, HireRight, obtaining and verifying information about my employment history, education, criminal record, credit history (if applicable), and any other details relevant to my employment eligibility.
3. I acknowledge that the information obtained during the background check will be used for employment purposes only and will remain confidential.
Authorization
By signing below, I authorize HireRight and Growth & Empowerment Mental Healthcare Services, LLC to perform a background check and release any findings to authorized personnel involved in the hiring process.
Name - Printed

First NameLast Name
Signature

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Should be Empty:

Rows	No Experience	Some Experience	Proficient	Expert
Reviewing clinical documentation (e.g., SOAP notes, treatment plans)
Auditing for Medicaid, OMHAS, or CARF compliance
Coaching or training others on documentation quality
Using Google Workspace (Docs, Sheets, Drive) to manage QA work
Conducting data analysis or quality improvement tracking
Communicating professionally with cross-functional teams
Working independently and managing multiple priorities

Rows	No Experience	Some Experience	Proficient	Expert
Completing SOAP notes and treatment plans within the required timeframe
Delivering therapy in schools, homes, or community-based settings
Documenting in alignment with OMHAS, CARF, and Medicaid standards
Using Electronic Health Records (EHRs) to document clinical work
Using Google Workspace (Docs, Sheets, Drive) to manage work
Communicating professionally with cross-functional teams
Working independently and with a larger team
Providing therapy to children, adolescents, adults, or families

Rows	No Experience	Some Experience	Proficient	Expert
Using supervision documentation tools (e.g., logs, agendas, evaluations)
Coaching clinicians on documentation quality and compliance
Supporting clinicians with ethics, boundaries, or crisis concerns
Participating in clinical leadership meetings or interdisciplinary teams
Communicating professionally with cross-functional teams
Using Google Workspace (Docs, Sheets, Drive) to manage work
Working independently and with a larger team
Supervising pre-licensed clinicians in a behavioral health setting

Rows	No Experience	Some Experience	Proficient	Expert
Conducting psychiatric diagnostic evaluations
Managing psychiatric medications, including prescribing and monitoring
Working with youth, adolescents, or families in community settings
Using Google Workspace (Docs, Sheets, Drive) to manage work
Documenting clinical encounters using an EHR
Delivering services via telehealth and/or in-person visits
Working independently and with a larger team
Communicating professionally with cross-functional teams

Rows	No Experience	Some Experience	Proficient	Expert
Supporting youth or families in school, home, or community settings
Providing psychoeducation, life skills, or behavioral support
Documenting client services in an EHR or similar system
Working with children or adolescents with emotional/behavioral needs
Applying trauma-informed, culturally responsive support strategies
Working independently and with a larger team
Using Google Workspace (Docs, Sheets, Drive) to manage work

Please list three (3) professional references.

Equal Employment Opportunity Questionnaire

Tuberculosis Acceptance/Declination

Hepatitis B Acceptance/Declination

Vaccine Declination

DRUG-FREE WORKPLACE POLICY

DRUG AND/OR ALCOHOL TESTING CONSENT FORM

Background Check Authorization