Initial Clinical Position Application Form

Full Name *

First Name Middle Name Last Name

Current Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email Address *

Phone Number *

- Area Code Phone Number

Applying for Position *

Desired Practice Location *

Please indicate the populations with which you have competence in clinical assessment and treatment: *

Children Adolescents Adults Seniors

Are you licensed to practice independently as a Mental Health Clinician in the Commonwealth of Massachusetts? (You must be licensed to practice independently to join our group at this time) *

Yes No

License Type *

(ie LMHC, Psychologist, LICSW, Nurse Practitioner, MD, etc)

License Number *

License First Issued Date *

Date

Current License Expiration Date *

Date

If not licensed to practice independently as a Mental Health Clinician in the Commonwealth of Massachusetts, what is your licensure status? *

Licensed to Practice Independently in another US State or Territory Currently a Student Degree Completed, Acquiring Licensure Hours

How did you hear about this group practice? *

How soon can you start if an offer is made? *

Upload Resume/CV *

Upload Cover Letter *

By signing and/or submitting this form, you are agreeing to the following statements:

1. "I certify that all answers given by me are true, accurate and complete. I understand that the falsification, misrepresentation or omission of fact on this application (or any other accompanying documents) will be cause for denial of employment or immediate termination of employment and/or affiliation with this group, regardless of when or how it was discovered."

2. "I certify that the answers given herein are true and complete to the best of my knowledge. I also authorize investigation of all statements contained in this application as may be necessary in arriving at an employment, contracting, and/or group affiliation decision. In the event of employment, contracted relationship, or if group affiliation is granted, I understand that false or misleading information given in my application or interview(s) may result in discharge."

Signature *

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