Roamers Therapy Job Application

Applied Position *

Licensed Psychotherapist
Pre-Licensed Psychotherapist
Practicum Intern
Administrative Staff

Earliest Start Date *

Desired Salary

Have you ever been a Roamers Therapy client? *

Yes
No

Please note that we are unable to move forward with applicants who received services at Roamers Therapy in the past.

Personal Information

Full Name *

Preferred Name *

Pronouns *

Date of birth *//

Phone *

Email *

Address *

Address Line 1

City

State

Zip Code

Education

College or University (Bachelor's) *

Dates Attended *

Degree Obtained *

College or University (Master's or Doctorate) *

Dates Attended *

If you are applying for a practicum position, please enter your anticipated graduation date.

Degree Obtained *

If you are applying for a practicum position, please enter your anticipated degree.

Recent Work Experience (last 5 years)

Employer #1 Name *

Position(s) Held *

Start & End Date *

Duties & Nature of Work *

Reason for Leaving *

Employer #2 Name

Leave blank if not applicable

Position(s) Held *

Start & End Date *

Duties & Nature of Work *

Reason for Leaving *

Employer #3 Name

Leave blank if not applicable

Position(s) Held *

Start & End Date *

Duties & Nature of Work *

Reason for Leaving *

Employer #4 Name

Leave blank if not applicable

Position(s) Held *

Start & End Date *

Duties & Nature of Work *

Reason for Leaving *

Professional References

Please provide three professional references.

Reference #1 Full Name *

Please also include their titles (e.g., Dr, PsyD, LCSW, AMFT)

Relationship *

Phone *

Email *

Reference #2 Full Name *

Please also include their titles (e.g., Dr, PsyD, LCSW, AMFT)

Relationship *

Phone *

Email *

Reference #3 Full Name *

Please also include their titles (e.g., Dr, PsyD, LCSW, AMFT)

Relationship *

Phone *

Email *

Other Professional Information

Clinical License Type

e.g., LCSW, LCPC, PsyD

Clinical License Number

CAQH number

Leave blank if you do not have one.

NPI number

Leave blank if you do not have one.

Professional trainings attended

Clinical modalities/approaches that you are competent in

e.g., CBT, EMDR, Psychodynamic. Please also make sure to explain how you utilize these modalities in individual and couples therapy.

Languages that you are fluent in speaking

Other than English.

Identities *

Please only write the ones that you are comfortable disclosing to your prospective clients.

Writing Samples

Please make sure to review the instructions for each writing sample by clicking the links below the uploading areas.

Personal Biography *

Click or drag a file to this area to upload.

* Click here to read Personal Biography instructions.

Intersectionality Statement *

Click or drag a file to this area to upload.

* Click here to read Intersectionality Statement instructions.

Intake Coordinator Writing Samples *

Click or drag a file to this area to upload.

* Click here to download Writing Samples instructions.

Things that bring you joy *

e.g., hobbies, activities, people, places.

Verifications

Do you have work authorization at U.S.? *

Yes
No

Have you ever been convicted of a felony? *

Yes
No

Would you be willing to consent to a pre-employment background check? *

Yes
No

I certify that all answers given herein are true and complete to best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving an employment decision.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in immediate termination for cause.

Apply to join Roamers Therapy

Personal Information

Education

Recent Work Experience (last 5 years)

Professional References

Other Professional Information

Writing Samples

Verifications

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