RBT Application – Golden Grove Behavioral Health

Thank you for your interest in joining Golden Grove Behavioral Health. We are a privately owned and operated ABA therapy practice serving Louisa, Mineral, Orange, Zion Crossroads, Charlottesville, Palmyra, and surrounding communities. Please complete the application below.

Sign in to Google to save your progress. Learn more
Full Name *
Email *
Phone number *
Current Address *
Are you currently a Registered Behavior Technician (RBT)? *
RBT Certification Number
Date of Certification
MM
/
DD
/
YYYY
Are you in good standing with the BACB? *
CPR Certified? 
Clear selection
If Yes, Expiration Date?
MM
/
DD
/
YYYY
Do you have a valid driver’s license and reliable transportation? *
How many years of ABA experience do you have? *
Have you worked in (check all that apply): *
Required
Age groups you have experience with (check all that apply) *
Required
Briefly describe your ABA experience and responsibilities in previous roles: *
What days/hours are you available to work? *
How many hours per week are you seeking? *
Are you willing to travel to clients’ homes in Louisa, Mineral, Orange, Zion Crossroads, Charlottesville, Palmyra, and surrounding areas? *
Reference #1 (name, relationship, phone, email) *
Reference #2 (name, relationship, phone, email) *
Why are you interested in working with Golden Grove Behavioral Health? *
What strengths do you bring to a client care team? *
Do you have any questions or special considerations? *
*
Required
Signature (type your full name)
Date
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms