INDEPENDENT CONTRACTOR APPLICATION

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APPLICANT INFORMATION

TODAY'S DATE(Required)

FULL LEGAL NAME(Required)

First Last

ADDRESS(Required)

Street Address City State ZIP Code

PHONE NUMBER(Required)

OTHER PHONE

EMAIL(Required)

CURRENT EMPLOYMENT (AGENCY/COMPANY)(Required)

POSITION/TITLE(Required)

DEGREES HELD AND/OR EXPECTED

PLEASE LIST ANY DEGREES HELD OR EXPECTED DEGREES.(Required)

INSTITUTION

MAJOR

DEGREE

DATE

LICENSURE STATUS

PLEASE LIST ANY CURRENT, PREVIOUS OR EXPECTED LICENSURES.(Required)

LICENSURE TYPE

STATE

EXPIRATION DATE

PLEASE 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

ARE THERE COMPLAINTS PENDING AGAINST YOU BEFORE ANY OF THE ABOVE-NAMED BODIES?(Required)

Yes

HAVE YOU EVER HAD A CIVIL SUIT BROUGHT AGAINST YOU RELATIVE TO YOUR PROFESSIONAL WORK OR IS ANY SUCH ACTION PENDING?(Required)

Yes

IF YOU ANSWERED “YES” TO ANY OF THE ABOVE, PLEASE EXPLAIN HERE.

TRAINING AND CLINICALLY RELEVANT EXPERIENCE

PLEASE DETAIL YOUR PRACTICUM PLACEMENT, INTERNSHIP AND OTHER SUPERVISED CLINICAL EXPERIENCE.(Required)

AGENCY (INCLUDE CLIENT POPULATION/TREATMENT MODALITIES)

DATES

APPROXIMATE HOURS

RELEVANT JOB EXPERIENCE

NOTE: 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

There are no Entries.

Maximum number of entries reached.

HAVE YOU EVER BEEN ASKED TO RESIGN OR BEEN TERMINATED BY A TRAINING PROGRAM/EMPLOYER?(Required)

Yes

DO YOU HAVE EXPERIENCE AS A CLINICAL SUPERVISOR?(Required)

Yes

IF YOU ANSWERED “YES” TO ANY OF THE ABOVE, PLEASE EXPLAIN HERE.

GENERAL INFORMATION

PLEASE LIST RELEVANT PRESENT AND PAST VOLUNTEER WORK.(Required)

PROGRAM

ACTIVITIES

DATE

PLEASE 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)

REFERENCES

PLEASE 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)

NAME

AGENCY/INSTITUTION

PHONE

STATEMENT OF APPLICATION

PLEASE 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 LETTER

Accepted file types: pdf, txt, doc, docx, odt, ott, Max. file size: 30 MB.