Employment Application: Clinical

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The Patterson Center for Resiliency LLC provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to 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 federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion,
termination, layoff, recall, transfer, leaves of absence, compensation and training.

Applicant full name *

Preferred name (if any)

Date of birth *

YYYY

Full address, including number, street, city, state, and zipcode *

Length of time at this address *

Telephone number *

Email address *

Drivers' license state and number *

Are you at least 18 years of age? *

Yes

Available start date *

YYYY

How did you hear about this position being available? *

Are you related to anybody else that works for or interns at The Patterson Center for Resiliency LLC? If yes, please describe. *

If hired, are you able to submit proof that you are legally able to work in the US? *

Yes

Have you ever been fired from a job or forced to resign? If yes, describe. *

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. *

If you are a finalist for the position in which you are applying for, do you agree to submit to a criminal background check? *

Yes

Position applying for *

Preferred work hours/shift *

Are you able to perform the duties and tasks of the job in which you are applying for, with or without reasonable accommodations? *

Yes

Are there any reasonable accommodations that you would like to request at this time? If yes, please describe below. *

Educational history (please include Masters and Bachelors type, school name and address, and date) *

Additional trainings, certificates, or evidence based practices *

Additional skills, awards, or recognitions *

Current professional licenses that you hold (include state, type, and license number) *

NPI number *

CAQH ID (if applicable) *

Social Security Number (for credentialing purposes) *

Medicaid Provider ID (if applicable) *

Why are you interested in joining our team? *

What therapeutic services do you offer? (i.e. group therapy, individual therapy, family therapy, etc) *

What therapeutic modalities do you use and are trained in? *

What ages, genders, diagnoses, and other populations are you comfortable treating? *

What ages, genders, diagnoses, and other populations are you NOT comfortable treating? *

On average, how many minutes does a typical progress note take you to write? *

Are you comfortable with telehealth? *

Yes

How many clients are you comfortable seeing per day for one hour sessions? *

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. *

Please send The Patterson Center for Resiliency LLC (danielle@thepattersoncenter.org) 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? *

Yes

Skills test: Maribel is a 13yo female who has previously been diagnosed with bipolar disorder by a pediatrician. Maribel was adopted from foster care when she was 10 following parental substance misuse, neglect, and witnessing domestic violence. It is reported that Maribel has a family history of bipolar disorder and meth use. Maribel's adoptive parents report that Maribel is "moody," sometimes hyperactive and giddy, and other times sullen and withdrawn. Maribel can be irritable and impulsive, often resulting in "meltdowns" of yelling, arguing, slamming doors, and saying mean things to others. Her parents report this primarily happens at home, although can happen anywhere, and is "usually over nothing." They also report that Maribel often gets "stuck" on different concerns and is difficult to be soothed or reasoned with. She goes through periods of time where she lays in bed all day, stops showering or doing her makeup, speaks to her parents in grunts or moans, and only eats junk food. She often has difficulty concentrating at school and at home. She reports being tired, having trouble sleeping, and occasional nightmares. Maribel has had several falling outs with friends and does not appear very close to her family, stating "I can't trust anyone. I never get too close." Maribel displays low self-esteem. When you ask her what she wants to do after high school, she shrugs and states "I don't think it matters to anyone." Maribel declines talking about life in foster care or with her first family.

What would you diagnose Maribel with and why? *

Skills test: Please create a treatment plan for Maribel with at least one goal, one objective, and one intervention. *

Skills test: You have been meeting with Maribel for 2-3 months. Maribel usually sulks when she is meeting with you and does not seem very interested. She rarely talks but when she does, it is about surface level things, such as an exam or someone "annoying" at school. Maribel refuses to talk about being in foster care, her first family, or her adoption. Maribel's parents are becoming impatient at her lack of progress.

What would your next steps be?

Skills test: You are in your 10th session with Maribel. During this session, you discuss Maribel's fear that her boyfriend will break up with her and her anxiety about an upcoming test. When you challenge her on negative beliefs, Maribel shrugs and declines going further into the conversation. Maribel declines practicing a breathing technique and rolls her eyes. She was, however, willing to play a game of Uno at the end of session and laugh a bit with you.

Please write a mock progress note for Maribel's session in the following format.

1. Intervention (what you did)

2. Response (how the client responded to your intervention)

3. Therapeutic impact (How the client moved towards their treatment goals but still meet medical necessity)

4. Plan

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 The Patterson Center for Resiliency 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 The Patterson Center for Resiliency 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 CERTIFATION AND I UNDERSTAND AND AGREE TO ITS TERMS. (Please include full name and today's date.) *

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