Full Name
*
Email
*
Phone number
*
Current Address
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Are you currently a Registered Behavior Technician (RBT)?
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Yes
No
RBT Certification Number
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
CPR Certified?
Yes
No
If Yes, Expiration Date?
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Month
-
Day
Year
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Do you have a valid driver’s license and reliable transportation?
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Yes
No
How many years of ABA experience do you have?
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0-1
2-3
4-5
6+
Have you worked in (check all that apply):
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In Home Based ABA
Cinic Based ABA
School Based ABA
None
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+)
None
Briefly describe your ABA experience and responsibilities in previous roles:
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What days/hours are you available to work?
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How many hours per week are you seeking?
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10-15
15-20
20-25
25+
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
Reference #1 (name, relationship, phone, email)
*
Reference #2 (name, relationship, phone, email)
*
Why are you interested in working with Golden Grove Behavioral Health?
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What strengths do you bring to a client care team?
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Do you have any questions or special considerations?
*
*
I certify that the information provided is true and complete to the best of my knowledge.
I understand that employment is contingent upon background checks and verification of credentials.
Signature (type your full name)
Date
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Month
-
Day
Year
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