ART + PSYCH Contractor Application

1
Name
First Name
Last Name
2
Phone Number
Please enter a valid phone number.
3
Email
example@example.com
4
Please list your primary state of licensure as a doctoral level psychologist.(Please note at this time ART + PSYCH is only able to consider applicants who are fully licensed psychologists)
5
Are you PSYPACT Licensed?
YESNO
6
Please list any additional states in which you hold a license
7
Are you proficient in providing psychological services in language(s) other than English? If so, please list the language(s)
8
Please list the institution you earned your doctorate from and the type (PSYD, PHD)
9
Tell us just a few sentences about why you’re interested in working with ART + PSYCH.
Huge
Large
Normal
Small
Ok
Ok
10
Please give us a little information about any background training/expertise you have in this area or related areas (e.g. women’s mental health, perinatal mental health, fertility/infertility, evaluations, third party/forensic evaluations, etc). NOTE: This is not required for consideration for the position. We will provide training specific to this work.
Huge
Large
Normal
Small
Ok
Ok
11
We currently ask that our contractors offer a minimum of 5 available time slots per month for evaluations (more is great too). Time slots must be at least an hour in length. You have full flexibility to set them as you see fit and can make changes throughout the month as long as you are not already scheduled. Does this minimum requirement seem like it would work for you?
YESNO
12
Please upload a copy of your CV or other review of your professional history
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
Should be Empty: