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Therapeutic Employment Application
By completing this application you attest the information provided to be true to the best of your knowledge.
Email address *
Which position are you applying for? *
Required
Name: *
Other names by which you have been known *
Current Address *
Previous Address *
Phone number *
Driver's License State and Number *
Are you over the age of 18? *
Are you currently employed *
Required
Can we contact your current employer? *
Required
Date You Can Begin *
MM
/
DD
/
YYYY
Employment Sought *
Required
Are you legally able to work in the United States? *
Required
Do you have a high school diploma or equivalent? *
Required
Are you currently a Board Certified Behavior Analyst (BCBA), BCaBA, or RBT? *
Required
If yes to above, please provide your BCBA/BCaBA/RBT Number provided by the BACB. *
Have you completed the 8 hour supervision training and module? *
Required
How many hours of ABA have you implemented *
Do you have a CAQH number? *
Required
Do you have a NPI number? *
Required
If yes to above, please list your NPI number *
If yes to above, please list your CAQH number. *
Do you hold a Professional license in the state of Colorado? (LPC, LCSW, LMFT, etc.)? *
Required
If so, please list license and type: *
Are you currently credentialed/enrolled as a provider with any of the following funding sources? Check all that apply.
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