SECTION 1-General Information
County (TYPE IN ALL CAPS)
Name (TYPE IN ALL CAPS)
Other Last Names Used?
Phone
Email
Address
Date of Birth
MM
/
DD
/
YYYY
SSN
Driver's Liscense Number
What position are you applying for?
Mental Health Specialist
Licensed Therapist
Admin Team
Marketing
Family Advocate
Medical Director (MD)
Clinical Nurse Specialist
Psychiatrist
Mental Health Specialist
Are You a Licensed Provider?
Yes
No
Education: (List all Schools High & Beyond)
School Name - Dates Attended
Special Trainings
Do You Have Any Felony's?
Yes
No
If so, please explain the situation...
Have you ever lived outside of the state in the past 7 years?
Yes
No
If so, where?...
Available start date
MM
/
DD
/
YYYY
SECTION 2-Employment History (5 Years)
MENTORING / COUNSELING EXPERIENCE 1
****Include Mentor / Caregiving / Counseling Experience Here (Even if done Voluntary)****
Company 1 Phone
Employed 'From' and 'To' Dates
Salary
Position
Job Description
Reason for Leaving
MENTORING / COUNSELING EXPERIENCE 2
****Include Mentor / Caregiving / Counseling Experience Here (Even if done Voluntary)****
Company 2 Phone
Employed 'From' and 'To' Dates
Salary
Position
Job Description
Reason for Leaving
MENTORING / COUNSELING EXPERIENCE 3
****Include Mentor / Caregiving / Counseling Experience Here (Even if done Voluntary)****
Company 3 Phone
Employed 'From' and 'To' Dates
Salary
Position
Job Description
Reason for Leaving
Personal Reference 1
Please list 3 personal references we can call that you have known over 5 years.
(Include Full Name, Relationship, Phone, City/State, Years Known)
Personal Reference 2
(Include Full Name, Relationship, Phone, City/State, Years Known)
Personal Reference 3
(Include Full Name, Relationship, Phone, City/State, Years Known)
Professional Reference 1
Please list 3 Professional references we can call that you have worked with in the places listed in employment history.
(Include Full Name, Relationship, Phone, City/State, Years Known)
Professional Reference 2
(Include Full Name, Relationship, Phone, City/State, Years Known)
Professional Reference 3
(Include Full Name, Relationship, Phone, City/State, Years Known)
SECTION 3-New Hire & Emergency Information
Car Insurance Company
Health Insurance Company
Emergency Contact Name
Emergency Contact Phone
Please list any medical problems
Please list any allergies
Hospital Address
Hospital of Preference
SECTION 4-Interview Questions
1. What experience do you have working as mentor, counselor or caregiver?
2. In your opinion, what constitutes effective leadership?
3. What is your idea of an effective mentor?
4. Describe your style of communication.
5. What attributes do you posses, that you feel are beneficial to child/family?.
6. Describe your level of patience as it pertains to people.
7. Our program requires 20 hours per week of client interaction, describe how you will make this time fit into your weekly schedule.
8. Give an example of how you might set up a system of short term and long term goals for you client.
9. Do you have any experience dealing with addiction or drug related issues? If so, please explain.
10. Describe your ability to be able strike up conversations with people who you may not know.
Apply
Please wait...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20