Employment Application

Please List any professional licensure or certifications you may have:

1. Have you ever been convicted of (plead guilty or no contest) for ANY criminal offense of any type, including DWI, sexual assault, domestic violence, abuse/neglect of a child?     No   Yes    If yes, please provide date            
2. Are you currently working for another community based agency, licensed under the NC department of Health and Human Services, providing a similar service to Royal's House of Care?        No   Yes     If yes, please provide agency name     
3. Do you have a Provider license currently, as a provider with NC DHHS in NC?   No   Yes   If yes, list the agency name   
4. Are you in partnership (silent or otherwise)with another provider who provides Behavioral Health and Developmental Services, similar to Royal's House of Care?      No   Yes   If yes, the name of the agency and your position   
5. Have you ever been asked to resign from employment?   No   Yes    If yes, the name of the agency and position   
6. Have you ever been counseled, disciplined, terminated, or asked to resign as a result of workplace harassment, assaults of violence, threats of violence, violation of ethics, or inappropriate conduct?   No   Yes   Type Option 3      If Yes, date?   
7. How many years have you had as a qualified mental Health Professional working with adults?   Number   years
8. How many years have you had as a Qualified Mental Health Professional working with adolescents?   Number   Years
9. How many years have you been a Paraprofessional and/or Direct Support staff working with the SA population?   Number   Years
10. Do you have credentials as a Peer Support Specialist, LCAS, CDAC, Licensed Clinical Social Worker, or any other specialty that could assist in the mental health setting?