Heal & ReLeaf Family Counseling PC: Employment Application

Employment Application

Applicant Notice: Thank you for your interest in joining Heal & ReLeaf Family Counseling PC. Please complete this application in full.
- Equal Opportunity Employment: Heal & ReLeaf Family Counseling PC is an equal opportunity employer. We evaluate all qualified applicants without regard to race, color, religion, sex, gender identity or expression, sexual orientation, national origin, ancestry, age, marital status, protected veteran status, disability, or any other protected status under applicable federal, state, or local law.
- Fair Chance and Background Considerations Consistent with California law and applicable local ordinances, we will consider qualified applicants with criminal histories in a manner consistent with the Fair Chance Act.
- Reasonable Accommodation Heal & ReLeaf Family Counseling PC is committed to complying with the Americans with Disabilities Act (ADA), the Fair Employment and Housing Act (FEHA), and all applicable regulations. We provide reasonable accommodations to applicants and employees with disabilities to ensure equal access to the application process and to employment, unless doing so would result in undue hardship. Applicants who may require accommodation during the hiring process are encouraged to contact us directly.

Section 2 - Position Availability
Position applying for*
Date you can start*

MonthDayYear
Date
How did you hear about this position?
Do you need any physical accommodations to perform the work applied for?*

YesNo
If yes, please explain:
I can provide telehealth care from a private, HIPAA compliant location*

YesNo
I possess a valid CA driver's license and have reliable transportation to work in-person as needed at the Riverside, CA location*

YesNo

Section 4 - Education, Experience, Licensure and Credentials
Enter education information: Institution Name - Year From/To - Graduated (YES/NO) - Degree(s)
High School/GED:


College/University:


Graduate School: 


Other: 


Licensure & Credentials *
List professional license or certification (e.g., LMFT, LCSW, LPCC, Psychologist, AMFT/ASW/APCC): 
License number / Issuing state / Expiration date: 
 Has your license or certification ever been suspended or revoked (YES or NO)?
If YES, please explain, including dates of action and reinstatement: 

List NPI#:
Do you have an active CAQH profile for credentialing purposes (YES or NO)? 
List other language(s) spoken other than English:

List Electronic Health Record experience (i.e., SimplePractice, TherapyNotes, Other): 
 Clinical interest areas (i.e., Children, Teens, Adults, Couples, Family systems, Trauma, Depression, Anxiety, Perinatal mental health, Substance use, LGBTQIA+ affirming care, Other):
Voluntary Practice Preferences: These answers help with client matching and scheduling. They do not affect hiring decisions.
Preferred weekly caseload range: ______ to______ clients
Preferred hours (Mornings, Afternoons, Evenings, Weekends):
Populations you most enjoy serving:

Section 5 - References
List four professional references not related to you who have knowledge of your work performance within the last three years. A current or former supervisor is required.
Reference #1
Full Name*

First NameLast Name
Position Title *
Phone Number*

Area CodePhone Number
Email*
example@example.com
No. of Years Acquainted*
Reference #2
Full Name*

First NameLast Name
Position Title *
Phone Number*

Area CodePhone Number
Email*
example@example.com
No. of Years Acquainted*
Reference #3
Full Name*

First NameLast Name
Position Title *
Phone Number*

Area CodePhone Number
Email*
example@example.com
No. of Years Acquainted*
Reference #4
Full Name*

First NameLast Name
Position Title *
Phone Number*

Area CodePhone Number
Email*
example@example.com
No. of Years Acquainted*

Section 6 - File Uploads
Introductory Video: Please record a short 2-4 min. video (using Loom or any recording tool of your choice) and share the file link below.
In your 2–4-minute video, we'd love to hear: 1. Your ‘WHY’—What inspired you to become a therapist? 2. Your alignment—Why do you feel drawn to Heal & ReLeaf’s mission of trauma-informed healing? No need for polished production—authenticity matters most.
Cover Letter File Upload*

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Resume/CV File Upload*

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Employment Application