• Behavioral-Health Employment Application

    Complete the form for the role you’re applying to and upload your resume (other documents only if requested).

  • Applicant Information

  • Format: (000) 000-0000.
  • Preferred Contact Method*
  • Date Available to Start*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Employment Type Sought*
  • Availability by Days/Times
    Rows
  • Able to Work Evenings and Weekends?*
  • Able to Provide Community/Home-Based Services?*
  • Able to Provide Telehealth Services if Applicable?*
  • Able to Reliably Travel Throughout Coatesville/Chester County?*

  • Position Applied For

  • Position Applied For*

  • Education

  • Graduation date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Pennsylvania Professional Credentials

  • Do you currently hold a Pennsylvania LPC license?*
  • License expiration date
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Other licenses or credentials held
  • Are you enrolled or credentialed with Pennsylvania Medicaid/PROMISe or any behavioral-health MCOs?

  • Peer Support Qualifications

  • Do you currently hold Pennsylvania Certified Peer Specialist (CPS) certification through the Pennsylvania Certification Board?*
  • CPS certification expiration date*
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Would you like to acknowledge that you meet Pennsylvania peer-support lived-experience/recovery qualification standards, without providing diagnosis or detailed medical history?
  • Which peer support/recovery-oriented skills and experience do you have?*

  • Case Management Qualifications

  • Populations served
  • Areas of community-resource knowledge
  • Case management competencies
  • Level of proficiency in core case management tasks*
    Rows

  • Clinical Experience

  • Populations served*
  • Treatment settings*
  • Clinical assessment experience
  • Treatment planning experience
  • Therapy modalities delivered*
  • Crisis and safety intervention experience
  • Clinical specialties and approaches
  • Electronic health record systems used
  • Do you have clinical supervision experience?*

  • Employment History

  • Format: (000) 000-0000.
  • Employer 1 Start Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Employer 1 End Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Permission to Contact Employer 1*
  • Format: (000) 000-0000.
  • Employer 2 Start Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Employer 2 End Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Permission to Contact Employer 2
  • Format: (000) 000-0000.
  • Employer 3 Start Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Employer 3 End Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Permission to Contact Employer 3

  • References

  • Reference 1
  • Format: (000) 000-0000.
  • Reference 2
  • Format: (000) 000-0000.
  • Reference 3
  • Format: (000) 000-0000.
  • Do not list relatives as references.

  • Clearances / Screening / Job Requirements

  • Are you willing and able to complete all legally required pre-employment checks and clearances for this position?*
  • Which of the following current clearances or screenings do you already have?
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  • If driving is an essential duty for this role, do you have a valid driver’s license?
  • Do you have reliable transportation to meet job requirements?
  • If you will use a personal vehicle for work, can you meet agency automobile insurance requirements?
  • CPR/First Aid status

  • Skills

  • Documentation / EHR proficiency*
  • Microsoft / Google tools*

  • Document Uploads

  • Upload a File
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  • Upload a File
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  • Upload a File
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    Cancelof
  • Upload a File
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  • Upload a File
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  • Please do not upload documents containing unnecessary government ID numbers or sensitive medical information.

  • Applicant Questions

  • Background Check Disclosure & Authorization

  • As part of evaluating your application for employment, P.R.I.M.E. — Progressive Recovery Integrated Mental Health may obtain background information or a consumer report for employment purposes through a third-party consumer reporting agency. This may include criminal history, identity verification, employment and education verification, professional license or credential verification, motor vehicle records when driving is job-related, and other lawful employment-related information. The report will be used only for lawful employment purposes and handled in accordance with applicable federal and state law.
  • I have received and read the disclosure above and understand that a background report may be obtained.*
  • I voluntarily authorize P.R.I.M.E. — Progressive Recovery Integrated Mental Health and its authorized background-screening provider to obtain a consumer/background report about me for employment purposes.*
  • This authorization does not guarantee employment.
  • Background Check Authorization Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Certification and Electronic Signature

  • Should be Empty: