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Full Application

APPLICATION FOR EMPLOYMENT

Access Behavioral Health Center
We consider applicants for all positions without regard to race, color, sex, age, national origin, religion, physical or mental disability, gender identity, or sexual orientation
Employee Referral


Name
Address


Best time to contact you at home is:
If you are under 18 years of age, can you provide required proof of your eligibility to work?
Are you authorized to work in the United States?
(Proof of citizenship or immigration status will be required upon employment)
Have you ever filed an application with us before?
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Have you ever been employed with us before?
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Do any of your friends or relatives work here?
Are you currently employed?
May we contact your present employer?
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Are you available to work:
Part-time
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Can you travel if a job requires it?


EDUCATION

High School

Undergraduate College

Graduate College


Professional References

1
Name
2
Name
3
Name


EMPLOYMENT EXPERIENCE


Start with your present or last job. Include any job related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, sex, age, national origin, religion, physical or mental disability, gender identity, or sexual orientation.
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SPECIAL SKILLS

Do you type?
Working knowledge of computer software?
Word
MS Excel
MS PowerPoint
MS Access
Adobe
Clinician Skills:LPCCs, PCCs,LMFT,LISW,LPC, CDCA,Case Manager/QMHS
MHCenter
Physician Office Practice
Pediatrics


Licenses

If you are a licensed health care or dental provider)
Professional Licensure
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Has a state licensing authority ever revoked, suspended or placed conditions upon your professional license(s)?
Have you ever been investigated by, sanctioned by, or otherwise had your ability to participate as a provider in Medicaid, Medicare or other government sponsored health insurance program, been suspended, revoked, limited or terminated?

OTHER REQUIRED INFORMATION

1. Have you ever been terminated from, or asked to resign from a previous position?
2. Have you ever been convicted of, or plead guilty to, or plead nolo contendere (no contest) to a crime, or are you presently charged with a crime?
3. Have you ever had a complaint filed against you of client abuse, neglect or misappropriation of client funds or property?
Fallure to list convictions at the time of application may result in rejection of application or dismissal if hired.


APPLICANT'S STATEMENT


I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further under- stood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.
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Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Start your journey to transformative health today. Simply complete the form, and allow Access Behavioral Health to lead you toward holistic well-being.

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