Let’s work together Interlude Wellness PLLC Employment Application Name * First Name Last Name Email * Phone * (###) ### #### Birthdate: * MM DD YYYY Can you legally work in the United States? * Yes No Level of education * Please check all that apply High School Deploma or GED Associates Degree (AA, AS) Bachelor's Degree (BA, BS) Master's Degree (MSW, Psychology, Counseling) Doctorate (Ph.D., DSW, Psy.D.) From where did you receive your highest/most recent degree? (Name of school/college/university) * When did you complete your higest level of education? * MM DD YYYY What License do you currently have? * (Please check all that apply) LCSW LSW LCPC LPC LMFT CADC PEL What is your license number? * Do you currently have a CAQH acount * Yes No If you have a CAQH account, what is your CAQH #? How many years have you had your license? * To the best of your knowledge, what insurance companies have you been paneled with? (i.e., where are you "in network"?) * Check all that apply Blue Cross (BCBS) Aetna United Health Care (Optum) Cigna Medicare Medicade None of these Why are you interested in practicing at Interlude Wellness? * How many patients do you ideally want to see each week? * 10-15 15-20 20-25 25-30 30+ What services are you interested in? * Providing in office sessions Providing telehealth sessions Both in ofofice & telehealth sessions What types of patients do you want to work with? * Check all that apply Seniors (65+) Adults Adolescence / Teenagers Kids (Elementary school age) Young kids (3-6) Couples Families Groups What types of patients do you NOT want to work with? * Check all that apply Seniors (65+) Adults Adolescence / Teenagers Kids (Elementary school age) Young kids (3-6) Couples Families Groups When do you want to see patients in-person? Check all that apply Weekday mornings (8-11) Weekday afternoons (11-3) Weekday evenings (3-7) Weekday late (8-10) Saturday Saturday Describe your ideal schedule * If hired by Interlude Wellness, what date would you be able to start seeing patients? * MM DD YYYY Professional Reference #1 Please provide contact information (phone/email) of a professional reference. Do we have your permission to contact this reference? * Yes No Professional Reference #2 Please provide contact information (phone/email) of a professional reference. Do we have your permission to contact this reference? * Yes No Do you attest that all the information you've provided on this application is accurate and truthful? * Yes No Thank you for your interest in working at Interlude Wellness PLLC! A member of our team will review your application and contact you within five business days.
