Private Practice Therapist Application: PANS/PANDAS Child Specialist

Private Practice Therapist Application: PANS/PANDAS Child Specialist
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
How did you find out about us? *
What is your primary licensure or area of expertise?*
What is your professional license number?*
In what state(s) are you licensed?*
In what year were you initially licensed?*
Are you currently credentialed with any insurance companies?*

Aetna/CofinityBlue Cross Blue Shield of MichiganBlue Care Network HMO/POSI am not currently credentialedOther
How many years of experience do you have treating patients in an outpatient psychotherapy setting?*
How many clients would you desire to see per week?*
What are your preferred areas of specialization or interest? (check all that apply).*

Children (Under 14)High-risk childrenAdolescentsAdultsFamily counselingPANS/PANDASLGBTQIA+ & GenderTraumaGrief & LossDBTEMDRSuicide IdeationSelf-harmERP/OCDOther
Are you currently trained in DBT, EMDR, or ERP?*

YesNoOther
If yes, please provide detail.
Are you interested in becoming trained in DBT, EMDR, or ERP?*

I am interested in becoming DBT trainedI am interested in becoming EMDR trainedI am interested in becoming ERP trainedAll of the aboveI am not interested at this time
Do you have knowledge or interest in working with those with PANS/PANDAS or OCD?*

I do not have knowledge or interestI do not have knowledge but am interested in learning and serving this populationI have knowledge/experience and am interested in working with this populationOther
Please list any additional specialty practice areas or training beyond the educational requirements for licensure.*
Are there any populations that you're opposed to working with from a moral, safety, or competency point of view?*
Are you looking to transfer clients from another practice?*

YesNo
Have you or a close family member received services with us in the last 12 months?*

YesNoOther
How would you prefer to meet with clients?*

In-personVirtuallyCombination of both
What days and hours are you looking to work? *
Are you willing to work evenings or weekends?*

YesNoOther
We are primarily looking for a clinician with after school and/or weekend availability, who can meet clients virtually. Are you available within these parameters?*

YesNoOther
What are your wage/salary expectations? Please note that hourly rates will depend on caseload, experience, and licensure. *
Are you looking for a part time or full time position?*

Part timeFull time
Do you understand that this is a 1099 position that does not include benefits, with the opportunity to build to a full time position?*

YesNo
We do not have a non-compete clause and understand that applicants may have multiple jobs while building their practice. Do you intend on working anywhere else during this process?*

YesNoOther
What is your expected start date?*

MonthDayYear
Date
Do you have interest in providing any of the following services?*

Individual therapyGroup therapySupervision of limited licensed cliniciansLeadership roles
Please describe any experience you have in the services listed above:*
What treatment approaches or theory drives your clinical interventions and why?*
How would you describe yourself as a therapist?*
Tell us about your professional goals/ambitions:*
What drew you to our practice, and why would you be a good fit?*
Please submit your cover letter. *

Cancelof
Please submit your resume.*

Cancelof
Please submit at least two work or academic related references.*

Cancelof
If you would like to attach a brief video introducing yourself, please upload your attachment here.

Cancelof
Optional Professional Disclosure Statement (if you have one):

Cancelof
Should be Empty: