Employment Application Form

Premier Mental Health and Wellness Employment Application

Fill the form below accurately indicating your potentials and suitability to job applying for.
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
What insurance(s) are you credentialed with?*

AetnaMedicareBCBSMedicaidCignaUHC/UMROther (please specify)None
What license(s) do you currently have?*

LPCLMSWLCSWLPC-AssociateLMFTLMFT-AssociatePMHNP-BC without DEAPMHNP-BC with DEAOther (please specify)
Are you open to seeing Medicare patients?*

YesNoNot sure, but I'm willing to explore
What type of position are you looking for? Select all that apply.*

Part-timeFull-time1099W2 positionEvening and/or weekend availability
When are you looking to start?*

ASAP1-2 weeks1-2 months3+ months
Once established, the ability to be hybrid is an option for our employees and we offer flexible scheduling. By applying, you are aware providing services located at 1835 W. Main St. in Gun Barrel City will be required.*

Yes
What are your preferred client populations or specialties?*
Tell us a little about why you are interested in joining our practice and what you look for in a working environment.*
Is there anything else you would like us to know about you?
Resume and Files

Cancelof
References

Please list two (2) references that are familiar with your work life, such as a colleague or co-worker. You may skip this section if these are included on your resume.
Reference
Reference
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