Rehabilitative Services Application

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By completing this application you attest the information provided to be true to the best of your knowledge.

Email *

Name *

First and last name

Current Address *

Previous Address *

Phone number *

Driver's License State and Number *

Date of Birth *

YYYY

Are you currently employed *

Yes

Can we contact your current employer? *

Yes

Does Not Apply

Date You Can Begin *

YYYY

Employment Sought *

Full Time

Part Time

Temporary

Are you legally able to work in the United States? *

Yes

Are you 18 years old or older?

Yes

Clear selection

Do you have a high school diploma or equivalent? *

Yes

Please indicate your Licensure *

Occupational Therapist (OT)

Speech and Language Pathologist (SLP)

Physical Therapist (PT)

Other:

Please provide your license number *

Do you have a CAQH number? *

Yes

If yes to above, please list your CAQH number. *

Are you currently credentialed/enrolled as a provider with any of the following funding sources? Check all that apply.

Medicaid

Anthem BCBS

Aetna

United Behavioral Health

Tricare

CIGNA

Kaiser

Other:

Please detail your highest earned degree with the NAME of INSTITUTION, TYPE of DEGREE and DATE DEGREE was RECEIVED. *

If you have any other degree, please detail with the NAME of INSTITUTION, TYPE of DEGREE and DATE DEGREE was RECEIVED.

Please list your most recent employment history, providing the NAME of EMPLOYER, JOB TITLE, DUTIES, DATES of EMPLOYMENT and PAY RATE. *

Please list your next most recent employment history, providing the NAME of EMPLOYER, JOB TITLE, DUTIES, DATES of EMPLOYMENT and PAY RATE. *

References: Please list THREE individuals (not related to you) who are familiar with your work related skills. Include their NAMES, COMPANIES, PHONE NUMBERS, EMAIL ADDRESSES and YEARS ACQUAINTED. *

Have you ever been charged or convicted of a felony or misdemeanor? *

Yes

If yes to above, please give a brief explanation.

Has your name, or any names you have used, been noted in a CPS case, in any state? *

Yes

If yes to above, please give a brief explanation.

Have you ever had more than one Social Security number? *

Yes

If yes to above, please least all social security numbers.

Have you ever gone by any other name(s), including a maiden name? *

Yes

If yes to above, please list all names you have used, nationally and internationally.

Do you have current First Aid certification? *

Yes

Do you have current CPR certification? *

Yes

Please list any other pertinent certification(s) you may have.

Describe your overall availability. i.e. weekends, morning, etc. *

We often provide therapy services in our clients' homes, in addition to our offices. If you were to visit a client residence, to what area(s) are you willing to drive? i.e. Lakewood, Aurora, Ft Collins, etc. *

Please describe your experience, if any, providing rehabilitative services to individuals with behavior disorders. If none, briefly describe your overall experience in OT/SLP/PT *

Please describe how you handle stressful situations. *

Please describe how you work independently within a team. *

Please provide an emergency contact with a phone number: *

By checking the box below you attest that all the provided information is true to the best of your knowledge. *

I attest this information to be true.

Required

Today's Date *

YYYY

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