Application – The Therapist PLC

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Available Start Date

Position

Are you independently licensed?

Yes
No

Please provide license type *

Please provide license state and number if applicable

Do you have restrictions on your license? Please explain

If not licensed, are you seeking internship/supervision?

Yes
No

What ages are you seeking to work with? *

How many years experience do you have?

How many hours a week are you seeking?

Are you available for evening hours?

Yes
No

Work Availability

Are you willing to complete a background check? *

Yes
No
Unsure

Are you comfortable working independently or with minimal supervision? *

Were you referred by someone?

Yes
No

Please list referral source

Please provide a summary of your ideal job, therapeutic interests, goals, preferred client, any certifications or trainings, any relevant information about you. Please attach your resume below. Thank you. *

Resume *

Drag & Drop Files, Choose Files to Upload

Contractor and Intern Application

Please complete the following form and include a copy of your resume. We will review it and reach out via email or phone. Thank you.

Monday:	9 a.m. – 5 p.m.
Tuesday:	9 a.m. – 5 p.m.
Wednesday:	9 a.m. – 5 p.m.
Thursday:	9 a.m. – 5 p.m.
Friday:	9 a.m. – 2 p.m.
Closed on all major holidays