Applicant Questionnaire
Applicant Details:
Full Name
First Name
Last Name
Preferred name if different than above
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you are not living in the area, what are your current plans to relocate?
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about us?
Please Select
Indeed
Website
Social Media
Current Staff Member
Other
If other, please specify
Highest Degree Earned
Master's in Counseling
Masters in Social Work
Doctorate (PhD/PsyD)
Other
If other, please specify
Licensure (check all that apply)
Licensed Professional Counselor (LPC)
Resident in Counseling (currently accruing hours toward licensure)
Resident in Counseling (contingent upon a supervisor)
Licensed Clinical Social Worker
Supervisee in Social Work (currently accruing hours toward licensure)
Supervisee in Social Work (contingent upon a supervisor)
Licensed Marriage and Family Therapist
Licensed Psychologist
Registered Behavioral Technician
Other
If other, please specify
Certifications (if any)
Settings previously worked in (check all that apply)
Outpatient clinic
Private practice
Hospital
School
PHP/IOP
Residential
Community Agency
Other
If other, than specify:
Why are you interested in joining Crescent Counseling Center?
Preferred work schedule
Full-time
Part-time
I'm not sure and would like more information
What populations you are most interested in working with? (ages, diagnoses, etc.)
Are you willing to work evenings?
Please Select
Yes
No
Please provide two professional references. At least one must be a supervisor. These individuals will only be contacted if a second interview is offered.
Rows
Name
Relationship
Phone #
Email
1
2
Please attach an updated resume (.pdf format)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: