Therapist Application Form

1
Name* This field is required.Enter your legal first and last name
First Name
Last Name
2
Email* This field is required.Enter a valid email address
example@example.com
3
Phone Number* This field is required.Enter your preferred contact number
Please enter a valid phone number.
4
City and State of Residence* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
What kind of compensation are you looking for?* This field is required.Select ONE.
Full-time (Exempt W-2)
Part-time contractor (1099)
Full-time contractor (1099)
6
Professional Credentials & Licensing* This field is required.Select ALL that apply
PsyD
PhD
LPC-A
LPC
LPC-S
LMFT-A
LMFT
LMFT-S
LMSW
LCSW
LCSW-S
Other
7
What state(s) are you licensed in?* This field is required.Select ALL that apply
Texas
California
Other
8
How many years of clinical experience do you have (excluding associate hours)?* This field is required.Select ONE.
<1 year
1–3 years
4–6 years
7–10 years
10+ years
9
Which settings have you worked in/are you currently working in?* This field is required.Select ALL that apply
IOP/PHP
Residential
Community Care
VA
Private Pay Agency
Private Practice
Other
10
Age Group* This field is required.For each population, select your level of experience/preference.
Advanced Experience / Prefer
Some Experience / Prefer
Willing to Learn / Prefer
Some Experience / Do Not Prefer
No Experience / Do Not Prefer
Youth (6-12)
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Row 0, Column 3
Row 0, Column 4
Adolescents (13-17)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Adults (18–64)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Older Adults (65+)
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Youth (6-12)
Adolescents (13-17)
Adults (18–64)
Older Adults (65+)
Advanced Experience / Prefer
Row 0, Column 0
Some Experience / Prefer
Row 0, Column 1
Willing to Learn / Prefer
Row 0, Column 2
Some Experience / Do Not Prefer
Row 0, Column 3
No Experience / Do Not Prefer
Row 0, Column 4
Advanced Experience / Prefer
Row 1, Column 0
Some Experience / Prefer
Row 1, Column 1
Willing to Learn / Prefer
Row 1, Column 2
Some Experience / Do Not Prefer
Row 1, Column 3
No Experience / Do Not Prefer
Row 1, Column 4
Advanced Experience / Prefer
Row 2, Column 0
Some Experience / Prefer
Row 2, Column 1
Willing to Learn / Prefer
Row 2, Column 2
Some Experience / Do Not Prefer
Row 2, Column 3
No Experience / Do Not Prefer
Row 2, Column 4
Advanced Experience / Prefer
Row 3, Column 0
Some Experience / Prefer
Row 3, Column 1
Willing to Learn / Prefer
Row 3, Column 2
Some Experience / Do Not Prefer
Row 3, Column 3
No Experience / Do Not Prefer
Row 3, Column 4
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Specific Populations* This field is required.For each population, select your level of experience/preference.
Advanced Experience / Prefer
Some Experience / Prefer
Willing to Learn / Prefer
Some Experience / Do Not Prefer
No Experience / Do Not Prefer
Court-Mandated Clients
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Females
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
LGBTQ+
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Males
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Minority/Immigrant
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Trauma Survivors
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Veterans/First Responders/Law Enforcement
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Court-Mandated Clients
Females
LGBTQ+
Males
Minority/Immigrant
Trauma Survivors
Veterans/First Responders/Law Enforcement
Advanced Experience / Prefer
Row 0, Column 0
Some Experience / Prefer
Row 0, Column 1
Willing to Learn / Prefer
Row 0, Column 2
Some Experience / Do Not Prefer
Row 0, Column 3
No Experience / Do Not Prefer
Row 0, Column 4
Advanced Experience / Prefer
Row 1, Column 0
Some Experience / Prefer
Row 1, Column 1
Willing to Learn / Prefer
Row 1, Column 2
Some Experience / Do Not Prefer
Row 1, Column 3
No Experience / Do Not Prefer
Row 1, Column 4
Advanced Experience / Prefer
Row 2, Column 0
Some Experience / Prefer
Row 2, Column 1
Willing to Learn / Prefer
Row 2, Column 2
Some Experience / Do Not Prefer
Row 2, Column 3
No Experience / Do Not Prefer
Row 2, Column 4
Advanced Experience / Prefer
Row 3, Column 0
Some Experience / Prefer
Row 3, Column 1
Willing to Learn / Prefer
Row 3, Column 2
Some Experience / Do Not Prefer
Row 3, Column 3
No Experience / Do Not Prefer
Row 3, Column 4
Advanced Experience / Prefer
Row 4, Column 0
Some Experience / Prefer
Row 4, Column 1
Willing to Learn / Prefer
Row 4, Column 2
Some Experience / Do Not Prefer
Row 4, Column 3
No Experience / Do Not Prefer
Row 4, Column 4
Advanced Experience / Prefer
Row 5, Column 0
Some Experience / Prefer
Row 5, Column 1
Willing to Learn / Prefer
Row 5, Column 2
Some Experience / Do Not Prefer
Row 5, Column 3
No Experience / Do Not Prefer
Row 5, Column 4
Advanced Experience / Prefer
Row 6, Column 0
Some Experience / Prefer
Row 6, Column 1
Willing to Learn / Prefer
Row 6, Column 2
Some Experience / Do Not Prefer
Row 6, Column 3
No Experience / Do Not Prefer
Row 6, Column 4
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Diagnoses* This field is required.For each diagnosis, select your level of experience/preference.
Advanced Experience / Prefer
Some Experience / Prefer
Willing to Learn / Prefer
Some Experience / Do Not Prefer
No Experience / Do Not Prefer
ADHD
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Anxiety
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Autism
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Bipolar Disorder
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Depression
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Eating Disorders
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Grief & Loss
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Intellectual Disability
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
OCD
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Personality Disorders
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
PTSD/Trauma
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Relationship Issues
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Substance Use Disorders
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
ADHD
Anxiety
Autism
Bipolar Disorder
Depression
Eating Disorders
Grief & Loss
Intellectual Disability
OCD
Personality Disorders
PTSD/Trauma
Relationship Issues
Substance Use Disorders
Advanced Experience / Prefer
Row 0, Column 0
Some Experience / Prefer
Row 0, Column 1
Willing to Learn / Prefer
Row 0, Column 2
Some Experience / Do Not Prefer
Row 0, Column 3
No Experience / Do Not Prefer
Row 0, Column 4
Advanced Experience / Prefer
Row 1, Column 0
Some Experience / Prefer
Row 1, Column 1
Willing to Learn / Prefer
Row 1, Column 2
Some Experience / Do Not Prefer
Row 1, Column 3
No Experience / Do Not Prefer
Row 1, Column 4
Advanced Experience / Prefer
Row 2, Column 0
Some Experience / Prefer
Row 2, Column 1
Willing to Learn / Prefer
Row 2, Column 2
Some Experience / Do Not Prefer
Row 2, Column 3
No Experience / Do Not Prefer
Row 2, Column 4
Advanced Experience / Prefer
Row 3, Column 0
Some Experience / Prefer
Row 3, Column 1
Willing to Learn / Prefer
Row 3, Column 2
Some Experience / Do Not Prefer
Row 3, Column 3
No Experience / Do Not Prefer
Row 3, Column 4
Advanced Experience / Prefer
Row 4, Column 0
Some Experience / Prefer
Row 4, Column 1
Willing to Learn / Prefer
Row 4, Column 2
Some Experience / Do Not Prefer
Row 4, Column 3
No Experience / Do Not Prefer
Row 4, Column 4
Advanced Experience / Prefer
Row 5, Column 0
Some Experience / Prefer
Row 5, Column 1
Willing to Learn / Prefer
Row 5, Column 2
Some Experience / Do Not Prefer
Row 5, Column 3
No Experience / Do Not Prefer
Row 5, Column 4
Advanced Experience / Prefer
Row 6, Column 0
Some Experience / Prefer
Row 6, Column 1
Willing to Learn / Prefer
Row 6, Column 2
Some Experience / Do Not Prefer
Row 6, Column 3
No Experience / Do Not Prefer
Row 6, Column 4
Advanced Experience / Prefer
Row 7, Column 0
Some Experience / Prefer
Row 7, Column 1
Willing to Learn / Prefer
Row 7, Column 2
Some Experience / Do Not Prefer
Row 7, Column 3
No Experience / Do Not Prefer
Row 7, Column 4
Advanced Experience / Prefer
Row 8, Column 0
Some Experience / Prefer
Row 8, Column 1
Willing to Learn / Prefer
Row 8, Column 2
Some Experience / Do Not Prefer
Row 8, Column 3
No Experience / Do Not Prefer
Row 8, Column 4
Advanced Experience / Prefer
Row 9, Column 0
Some Experience / Prefer
Row 9, Column 1
Willing to Learn / Prefer
Row 9, Column 2
Some Experience / Do Not Prefer
Row 9, Column 3
No Experience / Do Not Prefer
Row 9, Column 4
Advanced Experience / Prefer
Row 10, Column 0
Some Experience / Prefer
Row 10, Column 1
Willing to Learn / Prefer
Row 10, Column 2
Some Experience / Do Not Prefer
Row 10, Column 3
No Experience / Do Not Prefer
Row 10, Column 4
Advanced Experience / Prefer
Row 11, Column 0
Some Experience / Prefer
Row 11, Column 1
Willing to Learn / Prefer
Row 11, Column 2
Some Experience / Do Not Prefer
Row 11, Column 3
No Experience / Do Not Prefer
Row 11, Column 4
Advanced Experience / Prefer
Row 12, Column 0
Some Experience / Prefer
Row 12, Column 1
Willing to Learn / Prefer
Row 12, Column 2
Some Experience / Do Not Prefer
Row 12, Column 3
No Experience / Do Not Prefer
Row 12, Column 4
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13
Therapeutic Forms and Modalities* This field is required.For each modality, select your level of experience/preference.
Advanced Experience / Prefer
Some Experience / Prefer
Willing to Learn / Prefer
Some Experience / Do Not Prefer
No Experience / Do Not Prefer
Telehealth
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
ACT
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
CBT
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Couples Therapy
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
CPT
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
CPT (telehealth)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
DBT
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
EMDR
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
EMDR (telehealth)
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
ERP
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
ERP (telehealth)
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Family Therapy
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Group Therapy
Row 12, Column 0
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Row 12, Column 3
Row 12, Column 4
IFS
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
Individual Therapy
Row 14, Column 0
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Row 14, Column 3
Row 14, Column 4
Motivational Interviewing
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Row 15, Column 4
Person Centered
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Row 16, Column 4
Play Therapy
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Row 17, Column 4
Play Therapy (telehealth)
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Row 18, Column 4
Prolonged Exposure
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Row 19, Column 3
Row 19, Column 4
Prolonged Exposure (telehealth)
Row 20, Column 0
Row 20, Column 1
Row 20, Column 2
Row 20, Column 3
Row 20, Column 4
Psychodynamic
Row 21, Column 0
Row 21, Column 1
Row 21, Column 2
Row 21, Column 3
Row 21, Column 4
Solution-Focused
Row 22, Column 0
Row 22, Column 1
Row 22, Column 2
Row 22, Column 3
Row 22, Column 4
Telehealth
ACT
CBT
Couples Therapy
CPT
CPT (telehealth)
DBT
EMDR
EMDR (telehealth)
ERP
ERP (telehealth)
Family Therapy
Group Therapy
IFS
Individual Therapy
Motivational Interviewing
Person Centered
Play Therapy
Play Therapy (telehealth)
Prolonged Exposure
Prolonged Exposure (telehealth)
Psychodynamic
Solution-Focused
Advanced Experience / Prefer
Row 0, Column 0
Some Experience / Prefer
Row 0, Column 1
Willing to Learn / Prefer
Row 0, Column 2
Some Experience / Do Not Prefer
Row 0, Column 3
No Experience / Do Not Prefer
Row 0, Column 4
Advanced Experience / Prefer
Row 1, Column 0
Some Experience / Prefer
Row 1, Column 1
Willing to Learn / Prefer
Row 1, Column 2
Some Experience / Do Not Prefer
Row 1, Column 3
No Experience / Do Not Prefer
Row 1, Column 4
Advanced Experience / Prefer
Row 2, Column 0
Some Experience / Prefer
Row 2, Column 1
Willing to Learn / Prefer
Row 2, Column 2
Some Experience / Do Not Prefer
Row 2, Column 3
No Experience / Do Not Prefer
Row 2, Column 4
Advanced Experience / Prefer
Row 3, Column 0
Some Experience / Prefer
Row 3, Column 1
Willing to Learn / Prefer
Row 3, Column 2
Some Experience / Do Not Prefer
Row 3, Column 3
No Experience / Do Not Prefer
Row 3, Column 4
Advanced Experience / Prefer
Row 4, Column 0
Some Experience / Prefer
Row 4, Column 1
Willing to Learn / Prefer
Row 4, Column 2
Some Experience / Do Not Prefer
Row 4, Column 3
No Experience / Do Not Prefer
Row 4, Column 4
Advanced Experience / Prefer
Row 5, Column 0
Some Experience / Prefer
Row 5, Column 1
Willing to Learn / Prefer
Row 5, Column 2
Some Experience / Do Not Prefer
Row 5, Column 3
No Experience / Do Not Prefer
Row 5, Column 4
Advanced Experience / Prefer
Row 6, Column 0
Some Experience / Prefer
Row 6, Column 1
Willing to Learn / Prefer
Row 6, Column 2
Some Experience / Do Not Prefer
Row 6, Column 3
No Experience / Do Not Prefer
Row 6, Column 4
Advanced Experience / Prefer
Row 7, Column 0
Some Experience / Prefer
Row 7, Column 1
Willing to Learn / Prefer
Row 7, Column 2
Some Experience / Do Not Prefer
Row 7, Column 3
No Experience / Do Not Prefer
Row 7, Column 4
Advanced Experience / Prefer
Row 8, Column 0
Some Experience / Prefer
Row 8, Column 1
Willing to Learn / Prefer
Row 8, Column 2
Some Experience / Do Not Prefer
Row 8, Column 3
No Experience / Do Not Prefer
Row 8, Column 4
Advanced Experience / Prefer
Row 9, Column 0
Some Experience / Prefer
Row 9, Column 1
Willing to Learn / Prefer
Row 9, Column 2
Some Experience / Do Not Prefer
Row 9, Column 3
No Experience / Do Not Prefer
Row 9, Column 4
Advanced Experience / Prefer
Row 10, Column 0
Some Experience / Prefer
Row 10, Column 1
Willing to Learn / Prefer
Row 10, Column 2
Some Experience / Do Not Prefer
Row 10, Column 3
No Experience / Do Not Prefer
Row 10, Column 4
Advanced Experience / Prefer
Row 11, Column 0
Some Experience / Prefer
Row 11, Column 1
Willing to Learn / Prefer
Row 11, Column 2
Some Experience / Do Not Prefer
Row 11, Column 3
No Experience / Do Not Prefer
Row 11, Column 4
Advanced Experience / Prefer
Row 12, Column 0
Some Experience / Prefer
Row 12, Column 1
Willing to Learn / Prefer
Row 12, Column 2
Some Experience / Do Not Prefer
Row 12, Column 3
No Experience / Do Not Prefer
Row 12, Column 4
Advanced Experience / Prefer
Row 13, Column 0
Some Experience / Prefer
Row 13, Column 1
Willing to Learn / Prefer
Row 13, Column 2
Some Experience / Do Not Prefer
Row 13, Column 3
No Experience / Do Not Prefer
Row 13, Column 4
Advanced Experience / Prefer
Row 14, Column 0
Some Experience / Prefer
Row 14, Column 1
Willing to Learn / Prefer
Row 14, Column 2
Some Experience / Do Not Prefer
Row 14, Column 3
No Experience / Do Not Prefer
Row 14, Column 4
Advanced Experience / Prefer
Row 15, Column 0
Some Experience / Prefer
Row 15, Column 1
Willing to Learn / Prefer
Row 15, Column 2
Some Experience / Do Not Prefer
Row 15, Column 3
No Experience / Do Not Prefer
Row 15, Column 4
Advanced Experience / Prefer
Row 16, Column 0
Some Experience / Prefer
Row 16, Column 1
Willing to Learn / Prefer
Row 16, Column 2
Some Experience / Do Not Prefer
Row 16, Column 3
No Experience / Do Not Prefer
Row 16, Column 4
Advanced Experience / Prefer
Row 17, Column 0
Some Experience / Prefer
Row 17, Column 1
Willing to Learn / Prefer
Row 17, Column 2
Some Experience / Do Not Prefer
Row 17, Column 3
No Experience / Do Not Prefer
Row 17, Column 4
Advanced Experience / Prefer
Row 18, Column 0
Some Experience / Prefer
Row 18, Column 1
Willing to Learn / Prefer
Row 18, Column 2
Some Experience / Do Not Prefer
Row 18, Column 3
No Experience / Do Not Prefer
Row 18, Column 4
Advanced Experience / Prefer
Row 19, Column 0
Some Experience / Prefer
Row 19, Column 1
Willing to Learn / Prefer
Row 19, Column 2
Some Experience / Do Not Prefer
Row 19, Column 3
No Experience / Do Not Prefer
Row 19, Column 4
Advanced Experience / Prefer
Row 20, Column 0
Some Experience / Prefer
Row 20, Column 1
Willing to Learn / Prefer
Row 20, Column 2
Some Experience / Do Not Prefer
Row 20, Column 3
No Experience / Do Not Prefer
Row 20, Column 4
Advanced Experience / Prefer
Row 21, Column 0
Some Experience / Prefer
Row 21, Column 1
Willing to Learn / Prefer
Row 21, Column 2
Some Experience / Do Not Prefer
Row 21, Column 3
No Experience / Do Not Prefer
Row 21, Column 4
Advanced Experience / Prefer
Row 22, Column 0
Some Experience / Prefer
Row 22, Column 1
Willing to Learn / Prefer
Row 22, Column 2
Some Experience / Do Not Prefer
Row 22, Column 3
No Experience / Do Not Prefer
Row 22, Column 4
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14
Are you available to work outside of regular hours (M–F 9a–6p) at least 1 or 2 days a week?* This field is required.Select all that apply.
Mornings (7a–9a)
Evenings (6p–8p)
Saturdays (10a–12p)
Saturdays (12p–2p)
Sundays (10a–12p)
Sundays (12p–2p)
Cannot be available outside clinic hours
Other
15
List available hours per week* This field is required.(i.e. 5-8 M-F or 8-12 MWF)
16
What is your desired compensation range?* This field is required.
17
What is your desired hourly compensation range?* This field is required.
18
A typical full-time schedule includes 30 clinical hours and 10 hours of admin time for notes and meetings. Would you be interested in any of the following administrative opportunities for additional compensation?* This field is required.
Leading or participating in webinars / workshops
Community outreach and building partnerships
Developing policies and procedures
Supervising or mentoring junior clinicians / associates
Program development (e.g., new services, specialty tracks)
Internal training / staff education
Other
19
We will be running a background check before an official offer is made. Is there anything you would like to disclose before we proceed?Examples may include: Prior misdemeanors or felonies; lawsuits involving patients, employers, or professional practice; terminations or dismissals from past employment; or disciplinary actions or investigations related to licensing, ethics, or professional conduct.
Huge
Large
Normal
Small
Ok
Ok
20
Tell us about any unique qualities or experiences that you would like to share with us.
Huge
Large
Normal
Small
Ok
Ok
21
CV Upload* This field is required.
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