Indy Child Therapist Applicant Screening
Thank you for your interest in our open positions. In order to ensure we are interviewing the best potential candidates, we ask that you complete this form to help us learn more about you. A cover letter and resume are still necessary and you may attach them at the end of this screening tool.
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First and Last Name *
Email *
Phone number *
Are you eligible to work in the United States? *
Required
Has your license, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or certification board? If yes, explain *
Have you ever been denied being credentialed with any insurance company for any reason other than their panel was full? If yes, explain and which one(s) *
Have you ever been convicted of, pled guilty to, pled nolo contendere to, sanctioned, reprimanded, restricted, disciplined or resigned in exchange for no investigation or adverse action within the last ten years for sexual harassment, a felony, or ANY other illegal misconduct?  Or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offense or sexual misconduct? If yes to any explain *
Have you ever been terminated from or asked to resign from any employment, practicum, or internship position? Have you ever had a practicum, internships, or employment contract not renewed or ended early for any reason? Please explain any yes answers below.  *
Do you have to check yes to any of the questions listed in the CAQH disclosures not already addressed here? This includes malpractice, liability/claims, substance use, ability to perform job, sanctions, hospital privileges, medicaid/medicare participation, etc. If yes, explain *
Which position are you most interested in? (check all that apply) *
Required
Which position are you applying for? *
If you hold an associate license (LSW, LMFTA, LMHCA), when was this issued (need date listed in IN PLA)? How many hours of experience have you accumulated? How many hours of supervision have you accumulated?
If you have another job, please describe your intentions as far as continuing-or not-employment and how you will navigate schedules ideally. *
What hours are you looking for, including total number weekly as well as your availability (days and times)? *
Please note that our practice requires 8 hours of after 3pm availability during the week OR 4-5 hours after 3pm AND Saturday morning availability. 
What ages ranges would you like to work with? Do you have a specific age group you prefer? *
Please note that we are a CHILD therapy practice and as such do little work with adults outside of parents/families. If you want to work with primarily with 18+ this is NOT the position for you. 
** The positions we have open currently require working mainly with under 13 years of age. 
Describe why you like working with children in general, but specifically the age ranges you listed above? *
Describe your experience and comfort level with running groups? *
We are a collaborative team who meet regularly and desire to support each other and the practice; how can you contribute to this? *
What is your vision for your career/ plan for the next 3-5 years? Why are you interested in private practice? *
Please describe how private practice fits into your vision for your career.
Is there anything in the job description that would disqualify you, you have questions about, or that would make it difficult to move forward with employment? *
If you haven't already, please submit your cover letter and resume to admin@indychildtherapist.com
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