Therapy Café® Independent Contractor Application

Therapy Café® Independent Contractor Application

(Property of Therapy Cafe LLC)
Independent Contractor Application
Therapy Café® is committed to fostering a diverse and inclusive environment. We do not discriminate in theselection or engagement of independent contractors based on race, color, religion, sex, sexual orientation, genderidentity, national origin, disability, age, or any other characteristic protected by applicable law.

Please attach your resume and complete all questions or your application will be deemed incomplete and may not be considered. Please fill out each box. Applications with missing or invalid job numbers may not be considered for any position.
Name (First, MI, Last)*
NPI Number*
CAQH ID Number
Social Security Number or TIN*
Date of Birth*
Mailing Address*
City, State, and Zip Code*
Email*
Telephone (Home)
Telephone (Cell)*
JOB TYPE
Position of interest

Outpatient Telehealth TherapistOutpatient Mental Health Practitioner (In Office)Practicum/InternshipPsychology SupervisorSocial Work SupervisorProfessional Counselor Supervisor
Select the days available to work:

No PreferenceMon.Tues.Wed.Thurs.Fri.Sat.Sun.
I am seeking

Full-Time (32 hours plus)Part-Time (under 32 hours)
How many hours can you work weekly?
Can you work nights?
Date available to begin

MonthDayYear
Date
ADDITIONAL INFORMATION
I certify that I am a U. S. Citizen, permanent resident, or foreign national with authorization to work in the United States.

YesNo
Have you ever been employed by this company in the past?

YesNo
Have you ever received mental health services by this company?

YesNo
Have you ever been convicted of, or entered a plea of guilty, no contest, or had a withheld judgment to a felony?

YesNo
Have you ever been investigated, charged, or are currently being investigated with harm, neglect or abuse to a child or adult? If so, what were the results?

YesNo
Do you have a driver's license?

YesNo
License number
State of Issuance
Expiration Date

MonthDayYear
Date
Are you related to any current Therapy Café® employee?

YesNo
If YES, what are their names and their relationship to you?
How did you hear about this employment opportunity at Therapy Café®? Check all that apply

Walk-inWebsiteAd in IndeedAd in magazineJob Bulletin (Monster)Dept. of LaborEmployee ReferralJob Bulletin (Other)Other:
EDUCATION

	Yes	No
High School
GED
College
Trade School

WORK EXPERIENCE
Please list ALL work experience beginning with you most recent job held. Attach additional files if necessary.
Company
Supervisor Name
Hrs/week
Address
Start Date

MonthDayYear
Date
Starting Salary
City, State, and Zip Code
End Date

MonthDayYear
Date
Final Salary
Phone Number
Your last job title
Reason for leaving
List jobs you held, duties performed, skills used or learned, or promotions you received while working at the company.
May we contact this employer?

YesNo
Company
Supervisor Name
Hrs/week
Address
Start Date

MonthDayYear
Date
Starting Salary
City, State, and Zip Code
End Date

MonthDayYear
Date
Final Salary
Phone Number
Your last job title
Reason for leaving
List jobs you held, duties performed, skills used or learned, or promotions you received while working at the company.
May we contact this employer?

YesNo
REFERENCES
Please include name, phone number, and circumstances of your references. Please include three employer resources and three personal references.
1.*
Phone Number
Please enter a valid phone number.
Email
example@example.com
2.*
Phone Number
Please enter a valid phone number.
Email
example@example.com
3.*
Phone Number
Please enter a valid phone number.
Email
example@example.com
4.*
Phone Number
Please enter a valid phone number.
Email
example@example.com
5.*
Phone Number
Please enter a valid phone number.
Email
example@example.com
6.*
Phone Number
Please enter a valid phone number.
Email
example@example.com
DISCLOSURE QUESTIONS
1. Has your professional license or registration ever been terminated, stipulated, restricted, limited, conditioned, suspended, revoked, refused, voluntarily relinquished or not renewed by any licensing board or any health-related agency organization, or is there a review pending?

YesNo
2. Has your professional license or registration ever been investigated or is it currently being investigated and, if so, what were the results?

YesNo
3. Has your membership, participation, clinical privileges, or employment ever been denied terminated, stipulated, restricted, refused, limited, suspended, revoked, or not renewed by any peer review organization, third party payer, clinic, hospital, medical staff, or any health-related agency or organization, or is there a review pending?

YesNo
4. Have you ever voluntarily relinquished your membership, participation, clinical privileges or request for privileges employment, professional license, or registration in lieu of disciplinary action, or prior to or during an investigation into your professional conduct or competency?

YesNo
5. Has your membership or fellowship in any professional organization or your specialty board certification ever been voluntarily or involuntarily denied, terminated, restricted, limited, suspended, or revoked?

YesNo
6. Have you ever been reprimanded, censored, or otherwise disciplined by, or have you ever been subject to a corrective action agreement/plan with any licensing board, peer review organization, third party payer, clinic, hospital, medical staff, or any health-related agency or organization?

YesNo
7. Has your certificate or participation in any private, federal (i.e., Medicare, Medicaid, etc.) or state health insurance program ever been revoked or otherwise limited or restricted, or is any investigation or proceeding with respect to any such action presently underway?

YesNo
8. Are there any charges pending or are you currently charged with or have you ever been indicted or found guilty of a felony, gross misdemeanor, misdemeanor, or other offense?

YesNo
9. Have you ever been found liable, guilty, or responsible for sexual impropriety or misconduct or sexual harassment with a patient/client, co-worker, or other?

YesNo
10. Have you ever had any professional liability claims or lawsuits brought against you, including pending No claims or lawsuits, dismissed or dropped claims or lawsuits, settlements, or final judgments?

YesNo
11. Has your professional liability carrier ever refused or canceled your coverage or excluded you from performing any specific privileges within your specialty?

YesNo
12. Have you ever practiced within your profession without professional liability insurance??

YesNo
13. Do you have a physical or mental condition that would affect your ability, with or without reasonable accommodation, to provide appropriate care to patients/clients and otherwise perform the essential functions of a practitioner in your area of practice without posing a health or safety risk to your patients/clients? If yes, what accommodations would help you provide appropriate care to clients?

YesNo
14. Does your use (or have you been told that your use) of alcohol or drugs affect your ability, with or without reasonable accommodation, to provide appropriate care to patients/clients and otherwise perform the essential function in your area of practice without posing a health risk to your patients/clients? If yes, what accommodations would help you provide appropriate care to patients/clients, and perform other essential functions?

YesNo
15. Are you currently using illegal drugs?

YesNo
The following are questions related to your clinical practice and work availability. Please check all that apply.
Please list any other credentials, licenses, professional affiliations, etc., which are relevant to the job(s) for which you are applying. Please also enter NPI# in this box.
LICENSE/CERTIFICATION
If a license, certificate, or other authorization is required or related to the position of interest, complete the following:

Issued by/Location of issuing Authority (State of other authority) (City and State)
OTHER CREDENTIALS/LICENSES/PROFESSIONAL AFFILIATIONS
Please list any technical skills, clerical skills, trade skills, etc., relevant to this position. Include relevant computer systems and software packages of which you have a working knowledge, and note your level of proficiency (basic, intermediate, expert.)

All applicants are required to submit a cover letter, no longer than three pages, in a separate file, addressing the following items:

1. State your purpose for pursuing the position of interest with Therapy Café®.

2. Describe the personal qualities and professionally related experiences that qualify you for the position of interest.

3. Describe your theoretical orientation to counseling (ONLY: Outpatient therapists; Practicum/Internship.)

4. Provide information on your experience in working with individuals from diverse backgrounds and your commitment to understanding diversity.

5. Provide an overview of your ability to use technology.

I certify that the information provided in this application and all supporting documents is true, accurate, and complete to the best of my knowledge. I understand that any omission, misrepresentation, or failure to fully complete this application may result in disqualification from consideration for engagement or, if discovered after contracting, termination of my contract.

I authorize Therapy Café® to conduct a thorough investigation of all statements contained in this application and supporting materials, and I release Therapy Café® from any liability in connection with such investigation. I further authorize my references and former clients or business associates to provide complete and truthful information in response to any inquiries regarding my background, qualifications, and prior engagements, and I release them from any liability related to such disclosures.

If offered a contract, I agree to comply with all company policies and procedures applicable to independent contractors and, if requested, to submit to a background check, credit history review, and/or drug screening as a condition of my engagement. I acknowledge that this application does not constitute an offer of a contract, and if a contract is extended, it does not create an employment relationship. I understand that my engagement with Therapy Café® is as an independent contractor, and as such, either party may terminate the contractual relationship in accordance with the terms of the independent contractor agreement.

Additionally, I acknowledge that the credentialing process may take up to 120 business days to complete. If engaged, I will be required to provide proof of my legal authorization to work in the United States and to adhere to all applicable company and contractual policies.

Furthermore, I understand that once I begin accepting clients, I am required to provide at least 90 days’ written notice prior to ending my engagement with Therapy Café® to allow for the appropriate transition of client care and continuity of services.

By signing below, I affirm that I have read, understand, and agree to the terms stated above.
To be considered for a position of interest, the following items must be included in the application package. Please fax: (443) 342-2953, Email: karina@thetherapycafe.com or mail to 35 Duke Street Unit 763 Prince Frederick, MD 20678.

Completed and signed Employment Application FormCopy of transcripts of all post-secondary courseworkCopy of cover letter, resume or CV Copy of diploma from highest degree attained
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Date*

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Date
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Date application received

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Clinical Director Signature/Date

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