Therapy Café® Employment Application

Therapy Café® is an EEO/Affirmative Action Employer committed to excellence through diversity. Employment offers are made on the basis of qualifications and without regard to race, religion, national or ethnic origin, disability, age, veteran status or sexual orientation.

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)*

Position of interest

Select the days available to work:

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

Date

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

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

	Yes	No
High School
GED
College
Trade School

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

Date

Starting Salary

City, State, and Zip Code

End Date

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

Date

Starting Salary

City, State, and Zip Code

End Date

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

Please include name, phone number, and circumstances of your references. Please include three employer resources and three personal references.

1.*

2.*

3.*

4.*

5.*

6.*

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.

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)

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 on this application and its supporting documents are accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date.

I authorize Therapy Café® to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to submit to a physical exam, criminal and background investigation, and/or screening for illegal substance upon conditional offer of employment/contract I understand that this document is NOT an offer of employment/contract, and that an offer of employment or contract, if tendered, does NOT constitute a contract for continued guaranteed employment/contract. I understand that staff and contactors of Therapy Café® serve at-will, and the employment or contractor relationship may be terminated by providing 30 business days written notice. If employed, I will be required to furnish proof of eligibility to work in the United States and to comply with company departmental regulations. I understand that the first ONE-HUNDRED AND TWENTY DAYS of the contract/ employment represent a provisional period.

To be considered for a position of interest, the following items must be included in the application package:

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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Applicant Signature

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Date

Date application received

Date

Administrative Director Signature/Date

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Clinical Director Signature/Date

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Therapy Café® Employment Application

Employment Application

JOB TYPE

ADDITIONAL INFORMATION

EDUCATION

WORK EXPERIENCE

REFERENCES

DISCLOSURE QUESTIONS

LICENSE/CERTIFICATION

OTHER CREDENTIALS/LICENSES/PROFESSIONAL AFFILIATIONS

OFFICE USE ONLY