Clinical Employment Application

Employment Application
This application is designed to help us understand how you think, work, and perform in a structured, high-accountability environment. To achieve the best results, take your time to read each question carefully and provide clear, honest, and complete responses.

Many questions are scenario-based and intended to reflect real situations you may encounter in this role, so thoughtful answers matter. Before you begin, ensure you have your resume, relevant certifications, and work history readily available.

A well-prepared application not only improves your evaluation outcome but may also allow us to move forward in the process more efficiently.
SECTION 1 — APPLICANT IDENTITY
1A. First Name*
1B. Last Name*
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
YesNo
YesNo
1J. Work Authorization Status*
YesNoDepends
DelawareFloridaGeorgiaMarylandPennsylvaniaLouisianaTexas
DelawareFloridaGeorgiaMarylandPennsylvaniaLouisianaTexas
YesNoN/A
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
YesNo

3B. For Licensed clinicians:*

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

YesNoLimited
CAQHCommercial PayersVeterans Affairs Community CareMedicareMedicaid
SECTION 4 — TELEHEALTH COMPETENCY
54321
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
YesNo
If yes, describe your experience
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
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*
YesNo
SECTION 10 — TECHNOLOGY + AI ADAPTABILITY
YesNo
YesNo
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
YesNo
If yes, please explain:
YesNo
If yes, please explain:
SECTION 13 — COMPENSATION EXPECTATIONS
13A. Desired salary or hourly wage*
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*
YesNo
15D. Graduation Date:*
16. Graduate School*
Name of Graduate School Attended
16A. Number of Years Attended*
16B. Area of Study/Degree*
YesNo
16D. Graduation Date:*
YesNo
17A. School Name*
Name of Trade/Technical/Other School Attended
17B. Number of Years Attended*
17C. Area of Study*
YesNo
17E. Graduation Date:*
YesNo
18A. Current Employer*
Name of Current Employer or NONE if not Employed
18B. Position*
18C. Salary*
18D. Reason for Leaving?*
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*
YesNo
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

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