Step 1 of 6 16% EmailThis field is for validation purposes and should be left unchanged.APPLICANT INFORMATIONTODAY'S DATE(Required) MM slash DD slash YYYY FULL LEGAL NAME(Required) First Last ADDRESS(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PHONE NUMBER(Required)OTHER PHONEEMAIL(Required) CURRENT EMPLOYMENT (AGENCY/COMPANY)(Required)POSITION/TITLE(Required) DEGREES HELD AND/OR EXPECTEDPLEASE LIST ANY DEGREES HELD OR EXPECTED DEGREES.(Required)INSTITUTIONMAJORDEGREEDATE Add RemoveLICENSURE STATUSPLEASE LIST ANY CURRENT, PREVIOUS OR EXPECTED LICENSURES.(Required)LICENSURE TYPESTATEEXPIRATION DATE Add RemovePLEASE LIST ALL AREAS OF COMPETENCY OR PROFESSIONAL PRACTICE FOR WHICH YOU ARE LICENSED OR CERTIFIED.(Required)HAS A LICENSING BOARD, PROFESSIONAL ASSOCIATION OR EDUCATION/TRAINING INSTITUTION EVER TAKEN DISCIPLINARY ACTION OF ANY SORT AGAINST YOU?(Required) Yes No ARE THERE COMPLAINTS PENDING AGAINST YOU BEFORE ANY OF THE ABOVE-NAMED BODIES?(Required) Yes No HAVE YOU EVER HAD A CIVIL SUIT BROUGHT AGAINST YOU RELATIVE TO YOUR PROFESSIONAL WORK OR IS ANY SUCH ACTION PENDING?(Required) Yes No IF YOU ANSWERED “YES” TO ANY OF THE ABOVE, PLEASE EXPLAIN HERE. TRAINING AND CLINICALLY RELEVANT EXPERIENCEPLEASE DETAIL YOUR PRACTICUM PLACEMENT, INTERNSHIP AND OTHER SUPERVISED CLINICAL EXPERIENCE.(Required)AGENCY (INCLUDE CLIENT POPULATION/TREATMENT MODALITIES)DATESAPPROXIMATE HOURS Add RemoveRELEVANT JOB EXPERIENCENOTE: In accordance with Minnesota Stature 148 A., we are obliged to contact your employers over the last five years and ask whether they have knowledge of you having sexual contact with clients. Please note that paid internships are considered a form of employment.PLEASE LIST PRESENT AND PAST EMPLOYMENT IN MENTAL HEALTH RELATED SETTINGS INCLUDING PAID INTERNSHIPS FOR AT LEAST THE PAST FIVE YEARS. (Most Recent First)ADD EMPLOYMENT DATES NAME OF AGENCY TITLE RESPONSIBILITIES/DUTIES AGENCY CONTACT NAME AGENCY CONTACT TITLE AGENCY ADDRESS Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. HAVE YOU EVER BEEN ASKED TO RESIGN OR BEEN TERMINATED BY A TRAINING PROGRAM/EMPLOYER?(Required) Yes No DO YOU HAVE EXPERIENCE AS A CLINICAL SUPERVISOR?(Required) Yes No IF YOU ANSWERED “YES” TO ANY OF THE ABOVE, PLEASE EXPLAIN HERE. GENERAL INFORMATIONPLEASE LIST RELEVANT PRESENT AND PAST VOLUNTEER WORK.(Required)PROGRAMACTIVITIESDATE Add RemovePLEASE LIST ANY AREAS OF SPECIAL EXPERTISE.(Required)(i.e. DBT, EMDR, personality disorder counseling, family therapy, foreign language, etc.) EXPECTATIONS REGARDING LIFE DEVELOPMENT RESOURCES (LDR)WHY DO YOU WANT TO BE AN INDEPENDENT CONTRACTOR AT LDR?(Required)HOW DID YOU LEARN OF/BECOME ACQUAINTED WITH LDR?(Required)WHAT DO YOU EXPECT FROM THIS POSITION?(Required)WHAT IS YOUR PREFERRED NUMBER OF HOURS?(Required)WHAT IS YOUR PREFERRED ESTIMATED START DATE?(Required) MM slash DD slash YYYY REFERENCESPLEASE LIST THE NAMES, AGENCY/INSTITUTIONS; AFFILIATIONS AND PHONE NUMBERS AND/OR EMAIL ADDRESSES OF THREE PEOPLE WHO ARE FAMILIAR WITH OR WHO HAVE SUPERVISED YOUR CLINICAL WORK WITHIN THE LAST FIVE YEARS.(Required)NAMEAGENCY/INSTITUTIONPHONEEMAIL Add RemoveSTATEMENT OF APPLICATIONPLEASE READ THE FOLLOWING CAREFULLY.(Required)All information submitted by in this application is true to the best of my knowledge. I understand that any significant misstatement in, or omission from, this application may be cause for denial of appointment as an independent contractor or cause for dismissal from the position at LDR. By applying for an Independent Contractor position at LDR, I acknowledge that I have the responsibility to read, understand and act in accordance with all ethical and legal guidelines outlined by the organizations associated with and monitoring your license to practice, LDR independent contractor policies and peer review procedures. I authorize Roselyn Busscher PsyD, LP, or Michelle Frauenshuh, MA, LMFT, Co-owners of LDR to consult with persons or institutions with which I have been associated and with others, including past and present employers, who may have information bearing on my professional competence, character, and ethical qualifications. I release from liability Roselyn Busscher PsyD, LP and/or Michelle Frauenshuh MA, LMFT and LDR for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications. I also release from any liability all individuals and organizations who provide information to Roselyn Busscher PsyD, LP and/or Michelle Frauenshuh MA, LMFT in good faith and without malice concerning my professional competence, ethics, character, and other qualifications. I understand and agree that I will notify LDR of any changes in my job or training status, licensure, censure or sanction by professional bodies, or any other information relating to my ability to perform as an Independent Contractor at LDR. By checking this box, I agree to the privacy policy.RESUME UPLOAD(Required)Accepted file types: pdf, txt, doc, docx, odt, ott, Max. file size: 30 MB. ADD A COVER LETTERAccepted file types: pdf, txt, doc, docx, odt, ott, Max. file size: 30 MB. Δ
