keap-form-test - Freedom Within Center | Counseling

First Name

Last Name

Phone Number

How did you learn about us?

Licensure

Please note that we only hire those who have a California license in good standing.

License/Registration Number

License Expiration Date

Has your license/registration to practice in any jurisdiction ever been limited, suspended, or revoked?

Has there ever been legal action against you in your role as a therapist?

Have you ever been denied membership or renewal thereof or been subject to disciplinary action in any professional organization or licensing board?

Elaborate on any "yes" answers from above.

If you are an associate, are you on your second BBS registration number?

If you are an associate, how many hours have you accrued towards licensure?

Professional Experience

Please list all therapeutic modalities in which you are trained (CBT, Cognitive Processing Therapy, Emotion-Focused Therapy, Acceptance and Commitment Therapy, Prolonged Exposure Therapy, Mindfulness, Dialectical Behavior Therapy, EMDR, Other):

Have you participated in any certificated trainings? If yes, which trainings?

Please indicate all client issues in which you are trained and comfortable working (ie depression, anxiety, panic attacks, OCD, personality Disorders, trauma, PTSD, combat (military), chronic pain, medical issues, sexual Abuse, physical Abuse (experienced during childhood), domestic violence, veterans, couples therapy, relationship issues (individual), perinatal mood and anxiety disorders, grief and loss, other)

Do you have experience with military/Veterans? If so, please describe:

Do you have any bilingual abilities? If so, please elaborate.

Clinical Experience Desired

Work Location Preference

In Person at the Office only Virtual/TMH only Hybrid (combination of virtual and in person)

On a scale of 1-10, how detail-oriented are you? (10 being most detailed)

Do you have your own private practice or work in another group private practice? Are you intending to maintain your employment at another practice while employed at FWC?

Do you have any days off or vacation scheduled in the next 6 months?

Thank you so much for taking time to apply for a position with us! Upon reviewing your responses and resume, if you appear to be a good fit we will contact you to schedule a 20-30 minute initial video interview. Initial interviews are conducted by our Onboarding Coordinator.

Form Test

Therapist Initial Application for Hire

Licensure

Professional Experience

Clinical Experience Desired