Top 10 Reasons to Join M Group

MGROUP ALABAMA

DISPATCH #: (256) 489-4008 EMAIL: info@mgroupalabama.com ADDRESS: 300 Pelham Ave. SW (STE A4 #183), Huntsville, AL 35801
Hiring Application Form

Thank you for your interest in joining our team at MGroup Alabama, a full-service care and behavior service provider dedicated to delivering compassionate, personalized, and impactful support to our clients. Please take a few moments to complete this application form. Your information will help us learn more about you and how you can contribute to our mission. We look forward to the possibility of welcoming you to our team!
Top 10 Reasons to Join M Group

Full-service care and behavior service provider
1. Flexible Schedules.

2. Work-Life Balance.

3. Positive Impact on Community.

4. Great Company Culture & Values.

5. Abundant Training & Professional Development.

6. Reputation of Key Leaders.

7. Passionate Team.

8. Solid Paychecks & Compensation Packages.

9. Family-Oriented Business.

10. Experience Deep Sense of Accomplishment from Helping Others.

Confidentiality Agreement
I,   First Name   Last Name   , acknowledge that I have been informed of and understand the importance of confidentiality of any information regarding the Department of Human Resources, its facilities, employees, and/or clients.

I,   First Name   Last Name   , understand that the fact that an individual receives services from the department is privileged information. I understand that all information obtained pertaining to a client, shall be privileged and confidential. Any information regarding a client’s record shall not be discussed outside of work. No client information shall be released to any person or agency without the knowledge and consent of the client.

I,   First Name   Last Name   , understand that violation of this confidentiality agreement constitutes a violation of employee work rules. I further understand that any violation of this agreement may subject me to disciplinary action, including dismissal.
Name:*

First Name and Middle NameLast Name
Signature:*

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Witnessed by :*

First Name and Middle NameLast Name
Date:*

MonthDayYear

Application Requirements

Thank you for your interest in M Group Alabama. Please complete the enclosed materials to continue the review process.
Agency Employee Credentials/ Certification Form Medicaid Rehabilitative (Rehab) Services Agency Employee Certification
Name

First NameLast Name
Job Title
Employee's Credentials
Check all medicaid rehab services that apply based on the credentials listed above

Intake Evaluation (90791-HE)Treatment Plan Review (H0032)Individual Counseling (90834-HE) 45 minIndividual Counseling (90837-HE) 60 minFamily Counseling w/o patient (90846-HE)Family Counseling w/patient present (90847-HE)Multi-Family Group Counseling (90849-HE)Group Counseling (90853-HE)Basic Living Skills (Supervision) (H0036/H0036-HQ)Psychoeducational Services (Supervision) (H2027/H2027-HQ)Medical Assessment & Treatment (90862-HE)Mental Health Care Coordination (H0046)Crisis Intervention (H2011)Behavioral Health Placement Assessment (H0002-HE)Child/Adolescent Mental Illness Day Tx (H2012-HA)
Medication Administration & Monitoring:

Medication Admin – Injectable (90772-HE)Medication Admin – Oral (H0033 – HE)Medication Monitoring (H0034)
Diagnostic Testing by Psychologist:

(96130-HE) Test Eval (1st Hour)(96131-HE) Test Eval (Each addtl hour – when 31 min of work performed)(96136-HE) Test Admin/Scoring (1st 30 min)(96137-HE) Test Admin/Scoring (Each addtl 30 min – when 16 min of work performed)
Diagnostic Testing by Technician:

(96130-HE) Test Eval (1st Hour)(96131-HE) Test Eval (Each addtl hour – when 31 min of work performed)(96138-HE) Test Admin/Scoring (1st 30 min)(96139-HE) Test Admin/Scoring (Each addtl 30 min – when 16 min of work performed)Diagnostic Testing by Computer (96146-HE)
Documentation of Credentials: Provide documentation of credentials with the completed form.
- Licensed Professionals:
  A copy of the license is required for documentation of credentials.
  (1) Physician licensed under Alabama law
  (2) Psychologist licensed under Alabama law
  (3) Professional counselor licensed under Alabama law (ALC, LPC)
  (4) Marriage and family therapist licensed under Alabama law
  (5) Social worker licensed under Alabama law (LBSW, LMSW, LICSW)
  (6) Registered nurse who has completed a master’s degree in psychiatric nursing
- Unlicensed Professionals:
  Official transcripts are required for documentation of credentials for B.A., B.S., BSW, and graduate school degrees.
  The provider applicant must request the official transcripts to be sent by the college or university to the county office(s) where the application for certification is being made.
  The provider applicant is required to incur any costs associated with requesting transcripts.
Verification of Credentials: To be completed by DHR Staff only.
- To verify credentials for a Licensed Professional, a copy of the license is required.
- To verify credentials for an Unlicensed Professional, official transcripts are required to document B.A., B.S., and BSW degrees. For graduate school degrees, official transcripts are required to document the degree and completion of a clinical practicum.
ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD ABUSE / NEGLECT (CA/N) CENTRAL REGISTRY CLEARANCE
Requesting Person or Agency/Organization
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Telephone Number
Please enter a valid phone number.
Check All That Apply

Child Placing AgencyResidential Child Care FacilityChild Day / Night Care CenterFamily Day / Night Care HomeExempt Child Day Care CenteMedicaid Rehab. Provider DHR VendorOther (Please Specify)
The person whose name and identifying information, printed or typed below, will provide unsupervised care and supervision of children as an: ____ This person’s specific job/role is or will be:

EmployeeVolunteerOther
Name

First NameLast Name
Sex

MaleFemale
Race
DOB

MonthDayYear
Date
Current Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alias, Maiden & Prior Married Name(s)
Name & DOB of Spouse & Former Spouse(s)
Name & DOB of Children / Stepchildren
Alabama counties where person has lived and/or worked
Attach additional pages as needed to provide all information requested above.
To be completed by person being cleared
I authorize the Alabama Department of Human Resources to release information contained in the Child Abuse / Neglect Central Registry about me to the above named person/agency/organization. I hereby waive any right to any review or hearing to which I may otherwise be entitled. I further release the Department of Human Resources, its officers, and employees from any and all claims arising out of or in any way connected to the release or dissemination of any information concerning me.
Signature

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Date

MonthDayYear
Date
Signature of Witness

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Date

MonthDayYear
Date
To be completed by DHR
A search of the Alabama Child Abuse / Neglect Central Registry has been completed with the information provided to determine if the person identified above has been named as being responsible for child abuse or neglect in Alabama. DHR releases only that information which is necessary to discover or prevent child abuse / neglect.
Substantiated report (i.e., indicated) located. See attached information. Type Report:

Physical AbuseNeglectSexual AbuseMental Abuse / NeglectNo report locatedRequest DeniedOther
IF Request Denied
IF Other
Office of Child Protective Services
Date Completed

MonthDayYear
Date
Contracted Worker Application
Contractor Name:*

First Name and Middle NameLast Name
Phone Number:*
Please enter a valid phone number.
Email Address:*
example@example.com
Emergency Contact:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload your Social Security*

Cancelof
Upload your Driver's License*

Cancelof
Upload your School Credentials (ex: Diploma or GED) AND/OR Resume*

Cancelof
Upload your Resume*

Cancelof
Car Insurance (If applicable)

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Our agency serves an at-risk population of individuals with social and emotional needs. Some have been abused, abandoned, or neglected.
How do you feel about supervision/monitoring and supportive client behaviors with this agency?*
How do you balance your work and personal life?*
What types of clients do you find the most difficult to work with and why?*
What would you do if you have an emergency and need to call off from work?*
What techniques do you use in crisis intervention for an irate client?*
Client has a verbal conflict with another client under your supervision, you observe that if it continues, they may get physical, what do you do?*
Client attempts to run away from the group home, facility, or residence. What do you do?*
My signature below certifies that I understand that this is a contracted position for hire.
Contractor Signature:*

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Date*

MonthDayYear
Date
Supervisor Signature:*

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Date*

MonthDayYear
Date
Contractors, Welcome!
As a contracted worker for M Group Alabama, you will receive a 1099 at the end of the year.

You are responsible for paying taxes for the money that you receive. We do not make any deductions from your payroll. It would be wise to set up quarterly tax payments with the IRS.

Estimated quarterly tax payments are due four times per year:

April, June, September, and January.

• For the period of Jan 1 to March 31: April 15th

• For the period of April 1 to May 31: June 15th

• For the period of June 1st to August 31: September 15th

• For the period of September 11 to December 31: January 15th of the following year

It is good to set these dates in your calendar at the start of every tax year.

Note: You can account for your mileage, cell phone, office space etc.
Contractor Availability / Change of Availability Requst Form

Contractor: Show the times and days you are available for work. Whenever your schedule changes, request this form, complete & and return it to your manager or supervisor. Any changes must be presented to a manager or supervisor 10 days in advance.
Contractor's Name:*

First Name and Middle NameLast Name
Position:*
Availability:*

MondayTuesdayWednesdayThrusdayFridaySaturdaySunday
Select Shift:*
Manager Initials

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Notes/Explanations (ex; School Mon-Fri 7:00am - 3:00pm)
Should be Empty:

MGROUP ALABAMA

Hiring Application Form

Top 10 Reasons to Join M Group

Confidentiality Agreement

Application Requirements

Agency Employee Credentials/ Certification Form Medicaid Rehabilitative (Rehab) Services Agency Employee Certification

Documentation of Credentials: Provide documentation of credentials with the completed form.

Verification of Credentials: To be completed by DHR Staff only.

ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD ABUSE / NEGLECT (CA/N) CENTRAL REGISTRY CLEARANCE

Contracted Worker Application

Contractors, Welcome!

Contractor Availability / Change of Availability Requst Form