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Employment Application
It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on
race, age, color, sex, religion, national origin, disability or other protected classifications
Applicant Information
*
Indicates required field
Name
*
First
Last
Phone Number
*
Email
*
Date Available
*
Position Applied For
*
Desired Salary
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Are you a citizen of the United States?
*
Yes
No
If NO, are you authroized to work in the US?
*
Yes
No
Have you ever worked for this company?
*
Yes
No
If yes, when?
*
Have you ever been convicted of a felony?
*
Yes
No
If yes, explain:
*
Education
High School Name
*
Address
*
Start Date
*
End Date
*
Diploma
*
Did you graduate?
*
Yes
No
Collage
*
Address
*
Start Date
*
End Date
*
Diploma
*
Did you graduate?
*
Yes
No
Other
*
Address
*
Start Date
*
End Date
*
Diploma
*
Did you graduate?
*
Yes
No
References
Name
*
Relationship
*
Company
*
Phone Number
*
Email
*
Name
*
Relationship
*
Company
*
Phone Number
*
Email
*
Name
*
Relationship
*
Company
*
Phone Number
*
Email
*
Previous Employment
Company
*
Date Start
*
Date End
*
Job Title
*
Starting Salary
*
Ending Salary
*
Responsibilities
*
Reason for leaving
*
Phone Number
*
Email
*
Supervisor
*
May we contact your previous supervisor for reference
*
Yes
No
Company
*
Date Start
*
Date End
*
Job Title
*
Starting Salary
*
Ending Salary
*
Responsibilities
*
Reason for leaving
*
Phone Number
*
Email
*
Supervisor
*
May we contact your previous supervisor for reference
*
Yes
No
Company
*
Date Start
*
Date End
*
Job Title
*
Starting Salary
*
Ending Salary
*
Responsibilities
*
Reason for leaving
*
Phone Number
*
Email
*
Supervisor
*
May we contact your previous supervisor for reference
*
Yes
No
Military Service
Branch
*
Start date
*
End date
*
Rank of discharge
*
Type of discharge
*
If other than honorable, please explain
*
Disclaimer & Signature
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature
*
By typing your name, you accept and certify that your answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Submit
Home
Services
Telehealth Appointments
Safe and Sound Protocol
SSP FAQ
Individual Therapy
Family Counseling
Rates & Insurance
Clinical Staff
Mary Azar
Andrea Bain-Frye
Gina Bonino
Hannah Brenke
Kaneesha Brown
Nicole Earl
Erin Foreman
Cassandra Graff
Leslie Gray
Samantha Habusta
Kayt Harden
Jessica Huesman
Daniel Huesman
Michelle "Shelly" Kepford
Benjamin Leber
Krista McCulloch
Ken Miller
Kaitlin Nitz
Alysa Rohrer
Abby Ross
Aaron Textor
Katie Trout
Kayla Walczak
Brittney Wilson
Meggie Yoder
Amanda Zalenski
Office Staff
Desiree VanValkenburg
Faith Kutzly
Maria Williams
Jackie Nowowiejski
Resources
HiPAA Privacy Notice
Mental Health Links
Physical Health Links
Blog
About Us
Our Mission
Contact Us
Job Opportunities