Employment Application: Clinical Counselor 
Colorado Experiential Counseling, LLC is committed to providing equal employment opportunities to all candidates and employees, and we strictly prohibit any form of discrimination or harassment based on race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by applicable federal, state, or local laws.

This policy applies to all aspects of employment, including but not limited to recruitment, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.
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Applicant full name: 
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Preferred name (if any)
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Date of birth
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Full address, including number, street, city, state, and zip code
Your answer: 

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Length of time at this address:
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Telephone number:
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Email address:
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Drivers' license state and number:
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Are you at least 18 years of age?
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Available start date:
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How did you hear about this position being available?
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Are you related to anybody else that works for or interns at Colorado Experiential Counseling, LLC? If yes, please describe.
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If hired, are you able to submit proof that you are legally able to work in the US?
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Have you ever been fired from a job or forced to resign? If yes, describe.
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Have you ever been sanctioned, put on probation, or otherwise disciplined by your regulatory board or other entity for malpractice, ethical violations, or other activities as it relates to your field and related fields? If yes, please describe.
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If you are a finalist for the position in which you are applying for, do you agree to submit to a criminal background check?
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Position applying for: 
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Preferred work hours/shift. These are hours wished to work in office and virtually from home. 
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Are you able to perform the duties and tasks of the job in which you are applying for, with or without reasonable accommodations?
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Are there any reasonable accommodations that you would like to request at this time? If yes, please describe below.
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Educational history (please include Masters and Bachelors type, school name and address, and date)
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Additional trainings, certificates, or evidence based practices:
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Additional skills, awards, or recognitions:
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Current professional licenses that you hold (include state, type, and license number):
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NPI number:
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CAQH ID (if applicable):
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Social Security Number (for credentialing purposes):
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Medicaid Provider ID (if applicable):
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Why are you interested in joining our team?
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What therapeutic services do you offer? (i.e. group therapy, individual therapy, family therapy, etc)
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What therapeutic modalities do you use and are trained in?
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What ages, genders, diagnoses, and other populations are you comfortable treating?
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What ages, genders, diagnoses, and other populations are you NOT comfortable treating?
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On average, how many minutes does a typical progress note take you to write?
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Are you comfortable with telehealth?
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How many clients are you comfortable seeing per day for one hour sessions? 
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We would like to bring to your attention that our counselors are required to see at least 26 clients per week. Would you be comfortable managing that number of clients?
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Please list 3 academic or professional references that will be contacted. These references must not be related to you. Please include name, relation, phone, and email address. Do not provide government email addresses, as the reference form will usually not go through. Please also let your references know to check their spam.
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Please send Colorado Experiential Counseling, LLC (info@coloradoexperientialcounseling.com) copies of your resume, cover letter, unofficial transcripts, and any licenses held within 48 hours of completing this application. Are you able to do this?*

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I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be on the basis for rejection, or if employment commences, immediate termination. I authorize Colorado Experiential Counseling, LLC to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organization to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. If employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its CEO or director of employees, the employment relationship will be “at-will,” In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time, with or without cause. With appropriate notice and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Colorado Experiential Counseling, LLC except in a specific written contract of employment signed on behalf of the organization by its CEO, has the power to alter or vary the voluntary nature of the employment relationship. BY TYPING MY NAME BELOW, I ATTEST THAT I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS. (Please include full name and today's date.)
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