Application For Fully Licensed Clinician (LPC, LICSW, LMFT) Electronic Signature * My Electronic Signature and Date below confirms that I authorize Oddesty K LLC and it's partners to verify all information provided on this application. First Name Last Name Date of Birth * MM DD YYYY Social Security Number * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Driver's License State/Number * Email * Phone * (###) ### #### Have you ever been convicted of a felony? * Yes No Are you a part of any pending legal matters, pending charges? * Yes No License Type * LPC LICSW LMFT Professional License Number: * License Expiration Date * Describe Clinical Work Experience * (populations worked with, number of years of experience) Availability For Seeing Clients * Please select all that apply Mon - Friday 8am - 5pm Mon - Friday 5pm - 7pm Weekends Other Desired Number of Hours Per Week * Do You Currently Hold Valid Malpractice/ Professional Liability Insurance? * While, this is not a factor in employment decision, applicants will be required to obtain and maintain their own professional liability insurance at time of contract. Yes No Describe your therapy philosophy and most used theories/ modalities * Describe your experience with documentation and maintaining timely records. * Do you have experience using Electronic Health Records Systems? * While, not a condition for contract, applicants with experience will be preferred. Yes No Electronic Signature * My Signature below confirms that I Authorize Oddesty K LLC to verify any and all information that I have included in this application. My signature verifies that I have a state of Alabama issued professional license to provide mental health therapy independently. I understand that this position is a contract position (1099). First Name Last Name Today's Date * MM DD YYYY Your Application Has Been Received! You will hear back from us soon!
