Let’s work together Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Social Security Number * If you already have a National Provider Identification (NPI) number, please enter it below: Are you a citizen of the United States? * Yes No If “No”, are you authorized to work in the United States? * Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification “Form I-9” be completed for every new hire/Contractor and that within Three business days of beginning work every new hire/Contractor must present to the Company documentation establishing Their identity and authorization to work. This Federal requirement must be satisfied as a condition of working with this Company. YES No What Position are you interested in? * Mental Health Therapist Intern Licensed Associate Counselor Licensed Professional Counselor Office Staff/Admin or Other Are you licensed with the Arizona State Board of Behavioral Health Examiners or Colorado State Board of Professional Counselors? * Yes, I am licensed as an LAC with AZBBHE Yes, I am licensed as an LPC with AZBBHE Yes, I am licensed as an LPCC with Colorado Yes, I am licensed as an LPC with Colorado I am licensed in a different state No, I am not licensed Not Applicable for the position I am applying for If yes, what is your licensure credentials and number? What Date would you be available to start? * MM DD YYYY Desired Hourly Pay * $15-$20 $21-$25 $26-$30 $31-$35 $35-$40 $41-$45 $46-$50 $51-$55 $56-$60 $61-$65 $66-$70 How Did you Hear About Us? Have you ever been convicted of a felony? * No Yes Have you ever been accused of inappropriate sexual behaviors with regards to employment people you have worked with or clients? * No Yes Have you ever had a complaint filed against you with any agency entity or state board? * No Yes If you answered "yes" to any of the above questions, please explain. Experience / Knowledge Check * What does it mean to be a mandated reporter?: What are your strengths you can use in the position you are applying for? * What do you think will be challenging for you in the position you are applying for? * Tell us how you maintain a healthy work/life balance? * What are your beliefs about Self-Disclosure? * What areas would you like to improve or learn more about? * What areas do you feel you are well informed about, and what is your therapeutic modality you use or believe you will use most often? * What population(s) do you prefer not to work with and why? * Education * Name of High School Address Address 1 Address 2 City State/Province Zip/Postal Code Country Start Date * MM DD YYYY End Date * MM DD YYYY Did you graduate? * Yes with a High School Diploma Yes, with an equivalent No College (Name) * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Start Date * MM DD YYYY End Date * MM DD YYYY Did you Graduate? * Yes No Still working towards the Degree If yes, list degrees and/or credits earned * Specialized Training: College (name) Address Address 1 Address 2 City State/Province Zip/Postal Code Country Start Date MM DD YYYY End Date MM DD YYYY Did you Graduate? Yes No Still working on it If yes, list degrees and/or credits earned Specialized Training: College (name) Address Address 1 Address 2 City State/Province Zip/Postal Code Country Start Date MM DD YYYY End Date MM DD YYYY Did you Graduate? Yes No Still working on it If yes, list degrees and/or credits earned Specialized Training Describe any educational degrees, skills, training or experience you believe are relevant to the job you are applying for: And Please complete the details of each training down below Training Address Address 1 Address 2 City State/Province Zip/Postal Code Country Start Date MM DD YYYY End Date MM DD YYYY Certifications earned: Training Address Address 1 Address 2 City State/Province Zip/Postal Code Country Start Date MM DD YYYY End Date MM DD YYYY Certifications earned: Training Address Address 1 Address 2 City State/Province Zip/Postal Code Country Start Date MM DD YYYY End Date MM DD YYYY Certifications earned: Do you have a valid Fingerprint Clearance Card? * Yes No If yes, Expiration Date: MM DD YYYY Do you have a valid CPR and First Aid Certification? * Yes No If yes, Expiration Date: MM DD YYYY Do you have current Professional Liability Insurance? * Yes No If yes, Expiration Date: MM DD YYYY Line References * Please list three individuals unrelated to you with whom you have worked who know your qualifications for this position: First Name Last Name Relationship * Company and Position * Phone * Country (###) ### #### May We Contact this Person? * Yes No Name * First Name Last Name Relationship * Company and Position * Phone * Country (###) ### #### May We Contact This Person? * Yes No Name * First Name Last Name Relationship * Company and Position * Phone * Country (###) ### #### May We Contact This Person? * Yes No Previous Employment * Please complete all Full-Time or Part-Time employment beginning with the most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis. Include military assignments and voluntary employment, and provide 10 years of history. A separate sheet may be attached, and you will have an opportunity to send your resume to INFO@HEALINGHARTZE.COM as well. Please explain any gaps in your employment history. 1. Most Recent Previous Employer Name: Start Date * MM DD YYYY End Date * MM DD YYYY Phone (###) ### #### Supervisor Name * First Name Last Name Job Title * Starting salary per hour * $ Ending Salary Per Hour * $ Responsibilities * Reason for Leaving * May We Contact Your Previous Supervisor for a Reference? * Yes No, and I have stated why down below If you do not wish for your Previous Supervisor to be contacted, please state the reasons why. Second Previous Employment Name * Start Date * MM DD YYYY End Date * MM DD YYYY Phone (###) ### #### Supervisor Name * First Name Last Name Job Title * Starting salary per hour * $ Ending salary per hour * $ Responsibilities: * Reason for Leaving * May We Contact Your Previous Supervisor for a Reference? * Yes No, and I have stated why down below If you do not wish for your Previous Supervisor to be contacted, please state the reasons why. Third Previous Employment Name * Start Date * MM DD YYYY End Date * MM DD YYYY Phone * Country (###) ### #### Supervisor Name * First Name Last Name Job Title * Starting Salary Per Hour * $ Ending Salary Per Hour * $ Responsibilities * Reason for Leaving * May We Contact Your Previous Supervisor for a Reference? * Yes No, and I have stated why down below If you do not wish for your Previous Supervisor to be contacted, please state the reasons why. Please Explain Any Gaps in Employment * Have you ever been discharged or asked to resign from employment? * Yes, and I have clarified why down below. No Provide at least three Professional References: * First Reference First Name Last Name Profession * Relation * Phone (###) ### #### Email Second Reference * First Name Last Name Profession * Relation * Phone (###) ### #### Email Third Reference * First Name Last Name Profession * Relation * Phone (###) ### #### Email Name * I certify that the answers given here in and during the entire application process (including but not limited to information provided in resumes, attachments to this application, interviews or otherwise if applicable) are true and complete to the best of my knowledge. I understand that any misrepresentations, omissions of facts or incomplete answers, during the application process may disqualify me from further consideration for employment or becoming an Independent Contractor with Healing Hartze. I further understand that if employed or contracted, any misrepresentations or omissions of facts during the application process may be cause for my dismissal at any time without prior notice. I am agreeing to this by typing my full name down below: First Name Last Name Today's Date * MM DD YYYY Thank you for completing your Application with Healing Hartze. We will contact you after we review your information.
