Please complete the form below to continue your application with Roamers Therapy.

• There are two short writing prompts in this application. Make sure to review these writing prompts so that you can estimate the time it will take to complete this form.
• You can leave some of the fields empty or write "N/A" if necessary
• If you click the "SEND" button and nothing happens, try clicking again. If you clicked multiple times but did not see a "Your application is submitted" message, contact roamerstherapyllc@gmail.com for troubleshooting.

Position Applying for:

Earliest Start Date:

Desired Salary:

Full Name:

Preferred Name (required)

Pronouns:

Date of Birth:

Phone Number:

Address:

Zipcode:

Email:

Have you ever been a Roamers Therapy client? YesNo
Please note that we are unable to move forward with applicants who received psychotherapy services at Roamers Therapy.

Education

High School (Name, Dates Attended, & Degree Obtained)

College or University (Name, Dates Attended, & Degree Obtained)

College or University (Name, Dates Attended, & Degree Obtained)

Recent work experience (last 5-years)

Employer Name:

Position Held:

Dates Employed:

Job Duties:

Reason for Leaving?

Employer Name:

Position Held:

Dates Employed:

Job Duties:

Reason for Leaving?

Employer Name:

Position Held:

Dates Employed:

Job Duties:

Reason for Leaving?

Employer Name:

Position Held:

Dates Employed:

Job Duties:

Reason for Leaving?

Please provide three references & their contact information associated to psychotherapy

Do You have any additional Trainings?

Clinical license number (if you have one):

NPI number (if you have one):

CAQH number (if you have one):

Personal things (activities, hobbies, etc.) that bring you joy:

Writing samples

Personal Biography (Upload):

Click Here for Personal Biography Instructions!

Intersectionality Statement (Upload):

Click Here for Intersectionality Statement Instructions!

Are you a U.S Citizen? YesNo

Have you ever been convicted of a felony? YesNo

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

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

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

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

Signature:

Date of Signature: