Contact Info
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Licensing
Professional Title
License Number
Licensing State(s)
License Expiration Date
-
Month
-
Day
Year
Date
Are you in good standing?
Yes
No
Have you ever had your license suspended and/or revoked?
Yes
No
If so, explain:
Experience
Years of experience:
Less than a year
1-2 years
3-5 years
5+ years
Familiar tools:
M-FAST (Miller Forensic Assessment of Symptoms Test)
SIRS-2 (Structured Interview of Reported Symptoms)
MMPI-2-RF (Minnesota Multiphasic Personality Inventory – Restructured Form)
PCL-5 (PTSD Checklist for DSM-5)
TOMM (Test of Memory Malingering)
BDI-II (Beck Depression Inventory)
PHQ-9 (Patient Health Questionnaire – Depression)
GAD-7 (Generalized Anxiety Disorder Screener)
MoCA (Montreal Cognitive Assessment)
WAIS-IV (Wechsler Adult Intelligence Scale – optional for neuropsychs)
Clinical Interview & Functional Capacity Evaluation
I don’t currently use these tools but am willing to learn
Other
States you can legally see clients in:
Uploads
Resume/CV
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Copy of License
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Proof of Liability Insurance
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Available Days
M
T
W
Th
F
Maximum cases per week
Please Select
1
2
3
4
5
Agreement
Please download a copy of our contractor agreement form from the link and upload below https://docs.google.com/document/d/1J_Hz4qKl4zwtlr_OZ9OqeQqpQbUuqx_eVh8DxfnX-k4/edit?usp=sharing
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I acknowledge that I have reviewed the Independent Contractor Agreement provided by Cognitive Clarity, LLC. I understand that my participation in this network is as an independent contractor and not as an employee, and that I am responsible for maintaining all required licensure, insurance, and clinical judgment. I agree to abide by the terms outlined in the agreement.
Initials
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