Full Name
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Email
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Phone Number
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Current Address
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Are you currently a Board Certified Behavior Analyst (BCBA)?
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Yes
No
Certification Number
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Date of Certification
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-
Month
-
Day
Year
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Are you in good standing with the BACB?
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Yes
No
State Licenses Held (if any)
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CPR/First Aid Certified?
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Yes
No
How many years have you practiced as a BCBA?
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0-1
2-3
4-5
6+
Have you supervised RBTs or BCaBAs before?
Yes
No
Have you worked in (check all that apply):
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In Home ABA
Clinic Based ABA
School Based ABA
Age groups you have experience with (check all that apply):
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Early Intervention (0–5)
School-age (6–12)
Adolescents (13–18)
Adults (18+)
Briefly describe your ABA experience and specialties:
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What days/hours are you available to work?
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Are you seeking a part time or full time position?
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Part Time
Full Time
Are you willing to travel to clients’ homes in Louisa, Mineral, Orange, Zion Crossroads, Charlottesville, Palmyra, and surrounding areas?
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Yes
No
Are you open to supervision responsibilities?
Yes
No
Why are you interested in Golden Grove Behavioral Health?
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What strengths or specialties do you bring as a BCBA?
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Do you have any questions or considerations you’d like us to know?
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*
I certify that the information provided is true and complete to the best of my knowledge.
I understand this form is an inquiry and does not guarantee employment.
Signature (type full name)
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Date
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Month
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Day
Year
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