Application for Employment

Referred by:

PERSONAL DATA

Applicant Last Name:

First Name:

Middle Initial

Home Address

Social Security Number

Mailing Address

Personal Phone

Email Address

Are you 18 years of ago or older?

Yes No

Are you legally authorized to work in the United States?

Yes No

Will you now or in the future require sponsorship or employment visa status (e.g., H-1B status?)

Yes No

Have you applied at or worked for Beachside Adult andFamily Therapy, Inc. before?

Yes No

If yes, when and for which position? Please also include reason for leaving if applicable.

Have you ever been disciplined or fired for making threats or any incident involving violence?

Yes No

If yes, please explain:

Have you ever been disciplined or fired for excessive absenteeism or other?

Yes No

If yes, please explain:

JOB INTERESTS

Which days are you available for in-person appointments?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

When can you start?

** Credentialing usually takes 2-3 months if not already in-network

SKILLS

Select all skills applicable:

Clinical Therapy

DSM 5 Diagnosing

Jane App EHR

Microsoft Office

Interviewing/ Hiring

Therascribe

Treatment Planning

Utilization Review

Other

Other skills:

EDUCATION

High School - Name / Location

Graduated?

Yes No

Diploma, Degree, Certificate or Equivalency Exam?

POST SECONDARY EDUCATION & TRAINING

Add another school

List relevant technical education, training or experience you would like Beachside Adult and Family Therapy, Inc. to consider relevant to your job

List academic honors, scholarships, fellowships; memberships in academic honorary societies; participation in/offices held in job related activities.

Thesis or Significant Research

Papers/ Books Published

EMPLOYMENT RECORD

Add an employer

REFERENCES

Add Reference

PLEASE READ CAREFULLY BEFORE SIGNING. I hereby certify that the Information given by me Is true in all respects. I understand that misrepresentation or omission of facts may result in refusal to hire or in discharge.

Release: I authorize Beachside Adult and Family Therapy, Inc. and their representatives to contact my prior employers for the purposes of verification of the information I have supplied and release same from any liability resulting from information released. I authorize employers, schools, and other persons named on this application to certify the information on this application and authorize employers to provide information relevant to my job performance.

An offer of employment with Beachside Adult and Family Therapy, Inc. Is contingent on my providing sufficient documentation necessary to establish my identity to work in the United States. I also understand that a job offer is contingent upon successfully passing a drug and alcohol test and criminal background check. Other screenings may be conducted depending on position (i.e. a credit check may be completed for positions holding financial responsibility.) Appropriate notification and paperwork will be provided.

This application is not a contract of employment between the applicant and Beachside Adult and Family Therapy, Inc. and it does not modify Beachside Adult and Family Therapy, lnc.'s "at will" employment policy. Both an applicant employee and Beachside Adult and Family Therapy, Inc. have the right to terminate employment at any time, with or without advance notice and withor without cause.

My signature is evidence that I have read and agree with the above statements.

Signature:

Enter your full legal name

Date

PROVIDER PROFILE

NPI:

Please list any other names you have used (maiden, etc)

Languages Spoken (Other than English)

Other:

License Number

Issue Date:

Expiration Date:

Attach your license to practice:

Add file

Please upload a file

CREDENTIALING HISTORY

DEA Registration - CA

Yes No

Please enter certificate number, issue date, and expiration:

CDS Registration - CA

Yes No

Please enter certificate number, issue date, and expiration:

Please list child/ adolescent age range if different from above:

Attach ABA Certificate

Add file

Please upload a file

Do you have any of the following additional training or certifications (beyond the requirements for licensure) for Physical/ Sexual Abuse, Addictions/ Substance Abuse, Autism Spectrum Disorders, Child Abuse, Domestic Violence, Eating Disorders, Geriatrics, Neuropsychological Testing, Post- Partum Depression. Psychological Testing?

Independent licensure / certification

10-20 hours of documented training (continued education, etc.) in past 1 -2 years (and/or internship or postdoctoral fellowship in specialty)

200 hours of direct clinical contact in past 5 years

For which area(s) of expertise do you have the above additional training noted above?

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