Recruitment Application Form

Employment Interest Form
Personal Information:
Full Name

First NameLast Name
Phone Number
E-mail
example@example.com
Employment Desired:
Position Applying For
Date You Can Start

MonthDayYear
Date
How many hours a week are you interested in?
Salary Desired $
YesNo

Licensing/Credentialing Information:
License Type
License Number
State Licensed In:
YesNo
Approximately how many face to face hours have you completed?
YesNo
If yes, how many weekly appointments do you anticipate this will be?
YesNoUnsure
If Yes, please list any insurance companies you are credentialed with?
YesNo
If Yes, please explain:

Clinical Skills and Interests
Tell us about your clinical specialties.
What populations excite you? What special trainings or certifications do you already have?
Are there any populations that you're opposed to working with from a moral, safety, or competency point of view?
What are your views on therapist self-disclosure as part of the clinical relationship with clients?

Your Interest in Blue Oak Counseling Services:
What Drives you? What excites you most about the opportunity to work with our pratice?
Your Background: How does your experience and qualification align with the requirements of this role?
Shared Values: How do your core values connect with our mission and values?
Resume or CV:

Please upload your resume or CV below PDF format preferred
Cancelof

Thank you for your interest in Blue Oak Counseling Services. Unfortunately, Associates with a secondary registration number cannot work in a private practice setting.

You can still submit this form, however we encourage you to follow back up once you are licensed and we welcome you to re-apply at that time.

Send Application:
By clicking the submit button below, I certify that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected.

We will review all information submitted and will follow up via email with a determination or next steps.
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Signature

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