Quality Counseling Employment Questionnaire

First name

Last name

Email address

Phone number

What is your Clinical License in Connecticut?

LPC, LCSW, LMFT, LMHC etc.

Are you paneled with any Insurance?

Anthem BCBS Medicaid (Husky) Aetna Optum Cigna Other

Please tell us about your specialty (niche). List any Certifications, and Trainings

What population do you enjoy working with?

Are you willing to provide Face to Face in person services?

Yes No

Whats your ideal schedule?

Day time, Evenings, or Weekends

What is your ideal employment status?

Full Time

35 hours

Part Time

15 hours

Have you worked in Private Practice Before? or Currently?

Yes No

Please tell us about your mental health and counseling experience

Why do you want to work for a group practice? Why Quality Counseling?

What are your 1-3 business and professional goals?

What value can you bring to Quality Counseling?

How did you hear about us?

Attach Cover Letter and Resume You can add multiple files

Add file

Please upload a file