Anxiety & Depression

Clinician Application

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Applicants Information:

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Please let us know your name.

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Please let us know your email address.

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Answering "yes" to these questions does not constitute an automatic rejection for employment. Date of the offense, seriousness and and nature of the violation, rehabilitation and position applied for will be considered.
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Previous Employment:


EMPLOYER 1
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EMPLOYER 2
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I certify that my answers are true and complete to the best of knowledge. I authorize you to make such investigations and inquiries of my personal, employment, educational, financial and other related matters as may be necessary for an employment decision.I hereby release employers, schools or individuals from all liability when responding to inquiries in connection with my application.

In the event I am employed, I understand that false or misleading information given or interview(s) may result in discharge.
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