Employment Application

Employment Application

Clinical
I. INTRODUCTION
Welcome and thank you for your interest in joining Impireum.

This application serves as a structured pre-screening to identify candidates who align with our standards of trust, performance, and results. Each section is an opportunity to demonstrate your professionalism and fit.

To streamline your experience, we strongly recommend reviewing the Employment Application Guide before starting. Note that most candidates complete the application in ~10 minutes with it.

A strong submission may accelerate your progression and reduce the need for a formal interview.

We look forward to learning more about you.
II. APPLICATION INSTRUCTIONS (MANDATORY ACKNOWLEDGEMENT)

Required Checkbox (MUST SELECT TO CONTINUE)
Terms & Conditions:*

I confirm that I have read the Impireum Employment Application GuideI understand that incomplete applications will not be consideredI understand that required documents must be uploaded before proceeding
SECTION 1 — APPLICANT IDENTITY
1A. First Name*
1B. Last Name*
1C. Gender*

MaleFemaleOther
1D. Birth Date*

MonthDayYear
1E. Phone Number:*
1F. Email*

Confirmation Emailexample@example.com
1G. Address*

Street Address

Street Address Line 2

CityState

Zip Code
1H. Applied or worked Here Before?*

YesNo
1I. Willing To Relocate*

YesNo
1J. Work Authorization Status*
1K. Are you willing to provide services across multiple states via telehealth*

YesNoDepends
1L. List ALL states where you are currently licensed (if applicable)*

DelawareFloridaGeorgiaMarylandPennsylvaniaLouisianaTexas
II. List other states you are willing to obtain licensure in within 90 days*

DelawareFloridaGeorgiaMarylandPennsylvaniaLouisianaTexas
III. Do you currently hold or are you willing to obtain DEA licensure in multiple states (if applicable)?*

YesNoN/A
IV. PMHNP/PA Required Credentials:*

APRN Unrestricted LicenseDEA Unrestricted Registration in state appliedControlled Substance Registration (CSR) ) in state(s) where direct services will be provided (if required by state);Designated state(s) Prescription Monitoring Program (PMP)Not ApplicableOther
Section 2 - Position + Role Alignment
2A. Position Applying For*
(Select One)
2B. Why are you interested in working with Impireum?*

0/200
SECTION 3 — LICENSURE + CREDENTIALING
3A. Have you ever practiced in multiple states?”*

YesNo

3B. For Licensed clinicians:*

Rows	License Type	License Number	State	Expiration Date	Any Disciplary Action
1
2
3
4
5
6
7
8

3C. Are you familiar with telehealth regulations across states?*

YesNoLimited
3D. Have you completed credentialing with any of the following?”*

CAQHCommercial PayersVeterans Affairs Community CareMedicareMedicaid
SECTION 4 — TELEHEALTH COMPETENCY
4A. How comfortable are you delivering care via telehealth?*

54321
4B. Which platforms have you used?*

eCWZoomDoxyOther
4C. Describe how you would handle a telehealth visit where a patient is distracted:*
4D. Describe how you would handle a telehealth visit where a patient has poor connection:*
4E. Describe how you would handle a telehealth visit where a patient is emotionally distressed:*
SECTION 5 — VA COMMUNITY CARE EXPERIENCE
5A. Have you worked with VA Community Care or veterans before?”*

YesNo
If yes, describe your experience
5B. Are you comfortable working with (Select all that applies):*

PTSDDepressionAnxietyADHD in veteransOther
5C. What does serving veterans mean to you?*
SECTION 6 — KPI + PERFORMANCE MINDSET
6A. How many patients per day/week are you comfortable seeing?*
6B. What does high performance mean to you in a clinical role?*
6C. How do you manage documentation efficiency while maintaining quality care?*
6D. Describe a time you had to meet performance expectations or metrics*
SECTION 7 — CLINICAL JUDGMENT SCENARIOS

(SHORT ANSWER)
7A. A patient requests a specific medication that may not be clinically appropriate. How do you respond?*
Scenario 1
7B. A patient no-shows repeatedly. What steps do you take?*
Scenario 2
7C. You suspect ADHD but need further evaluation. What is your approach?*
Scenario 3
SECTION 8 — SERVICE LINE EXPERIENCE
8A. Multi-select

Psychiatry / medication managementTherapyADHD TestingNeurofeedbackSpravatoIV Hydration/WellnessOther
8B. Which of the above are you MOST experienced in and why?*
Scenario 3
SECTION 9 — AVAILABILITY + SCHEDULING
9A. Available start date*

MonthDayYear
Date
9B. Preferred Schedule*
9C. Evening/Weekend Availability*
9D. Full-Time/Part-Time*
9E. Are you able to see patients across multiple time zones?*

YesNo
SECTION 10 — TECHNOLOGY + AI ADAPTABILITY
10A. How comfortable are you using AI-assisted tools (e.g., intake automation, documentation support, call systems)?*

YesNo
10B. Are you open to working in a highly technology-driven environment?*

YesNo
10C. Suspension/exclusion/debarment from participation in federal health care programs (e.g. Medicare, Medicaid, CHIP);*

YesNo
SECTION 11 — CULTURE + ALIGNMENT
11A. What does patient-centered care mean to you?*
11B. How do you handle feedback and coaching?*
11C. Describe a time you improved your performance”*
SECTION 12 — COMPLIANCE + PROFESSIONALISM
12A. Ever terminated?*

YesNo
If yes, please explain:
12B. Any malpractice claims?*

YesNo
If yes, please explain:
SECTION 13 — COMPENSATION EXPECTATIONS
13A. Desired salary or hourly wage*
13B. Preferred Compensation Model*

SalaryPer VisitHybrid
SECTION 14 — DOCUMENT UPLOADS
Upload Active Professional Licenses (all states held)*

Browse Files

Cancelof
DEA License (for prescribing roles)

Browse Files

Cancelof
Controlled Substance Registration (CSR) (if applicable)

Browse Files

Cancelof
Board Certification(s) or relevant credentials

Browse Files

Cancelof
Certifications relevant to your specialty

Browse Files

Cancelof
Malpractice insurance documentation (if available)

Browse Files

Cancelof
Any additional supporting credentials

Browse Files

Cancelof
Resume/CV*

Browse Files
.pdf or .doc only Cancelof
SECTION 15 to 24— EDUCATION + REFERENCES
15A. College*
Name of College/University Attended
15B. Number of Years Attended*
15C. Area of Study/Degree*
15D. Graduated?*

YesNo
15D. Graduation Date:*
16. Graduate School*
Name of Graduate School Attended
16A. Number of Years Attended*
16B. Area of Study/Degree*
16C. Graduated?*

YesNo
16D. Graduation Date:*
17. Doctorate

YesNo
17A. School Name*
Name of Trade/Technical/Other School Attended
17B. Number of Years Attended*
17C. Area of Study*
17D. Graduated?*

YesNo
17E. Graduation Date:*
18. Currently Employed*

YesNo
18A. Current Employer*
Name of Current Employer or NONE if not Employed
18B. Position*
18C. Salary*
18D. Reason for Leaving?*
18E. May We Contact?*

YesNo
19. Other Qualifications*
List any other relevant certifications or qualifications
20. Reference 1*
Name of Reference
20A. Relationship*
20B. Phone*
20C. Years Acquainted*
20D. Email*
21. Reference 2*
Name of Reference
21A. Relationship*
21B. Phone*
21C. Years Acquainted*
21D. Email*
22. Reference 3*
Name of Reference
22A. Relationship*
22B. Phone*
22C. Years Acquainted*
22D. Email*
23. Are you Hispanic or Latino?*

YesNo
24. Regardless of your answer to the prior question, please indicate how you identify yourself. (Select one or More)*

Black or African American (Non-Hispanic/Latino)Hispanic/LatinoAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslandeWhiteOther
25. How did you hear about us?*
SECTION 25 — FINAL ATTESTATION
Terms and Conditions*
Signature*
Should be Empty:

Employment Application

I. INTRODUCTION

II. APPLICATION INSTRUCTIONS (MANDATORY ACKNOWLEDGEMENT)

SECTION 1 — APPLICANT IDENTITY

Section 2 - Position + Role Alignment

SECTION 3 — LICENSURE + CREDENTIALING

SECTION 4 — TELEHEALTH COMPETENCY

SECTION 5 — VA COMMUNITY CARE EXPERIENCE

SECTION 6 — KPI + PERFORMANCE MINDSET

SECTION 7 — CLINICAL JUDGMENT SCENARIOS

SECTION 8 — SERVICE LINE EXPERIENCE

SECTION 9 — AVAILABILITY + SCHEDULING

SECTION 10 — TECHNOLOGY + AI ADAPTABILITY

SECTION 11 — CULTURE + ALIGNMENT

SECTION 12 — COMPLIANCE + PROFESSIONALISM

SECTION 13 — COMPENSATION EXPECTATIONS

SECTION 14 — DOCUMENT UPLOADS

SECTION 15 to 24— EDUCATION + REFERENCES

SECTION 25 — FINAL ATTESTATION