Integral Health Associates
Employment Communication Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Education/Training/Certification
*
Psychiatrist (e.g. MD, DO)
Doctorate in Psychology or equivalent (e.g. PhD, PsyD)
Psychiatric Nurse Practitioner
Master's Level Clinician (e.g. LCSW, LPC, LMFT)
1. Please explain why you’re interested in working as part of the clinical team at Integral Health Associates. (2000 characters limit)
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0/2000
2. What would you consider to be your particular strengths as a clinician and how did these strengths develop over time? (2000 characters limit)
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0/2000
3. Please describe any special interests or reservations/limitations with respect to working with specific patient populations. (2000 characters limit)
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0/2000
4. Have you ever had your licensure, certification, clinical privileges, or insurability put on probationary status, denied, limited, or terminated due to cause?
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Yes
No
5. Have you ever had a legal claim filed against you related to your professional role?
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Yes
No
6. Are you currently under investigation by any licensing/certifying board or government entity in relation to your professional role?
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Yes
No
7. How many hours per week are you interested in working?
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8. Are you willing to see patients in-person at our office in New Haven at least one day per week?
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Yes
No
9. Please use this space to elaborate on any question(s) above or to add any additional information. (2000 characters limit)
0/2000
10. Please attach your CV to this submission (.pdf, .doc, .odt).
*
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