Clinician Application Form
Please complete the application form to apply for the position of Outpatient Therapist.
Full Legal Name
*
First Name
Last Name
Email Address
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Highest Level of Education
Please Select
High School Diploma
Associate Degree
Bachelor's Degree
Master's Degree
Doctorate
Position Applying For:
*
Please Select
Full Time Greensboro
Part Time Greensboro
Full Time Lumberton
Part Time Lumberton
Full Time Fayetteville
Part Time Fayetteville
Full Time Durham
Part Time Durham
Independent License to Practice
Yes
No
Years of Experience in Counseling
North Carolina Licensure Board and License #
*
Please describe your counseling approach and philosophy
Attestation:
By signing below, I hereby certify that, to the best of my knowledge, the provided information is true and accurate:
Signature
*
Date
*
-
Month
-
Day
Year
Date
Upload your Resume/CV
*
Upload a File
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