Licensed Clinical Therapist Application

Date of Application:*

Name:*

First Last

Please list any additional names you have used professionally. If there are no other names, you may skip this question.

First Last

Position Applying For:*

Email:*

Enter Email Confirm Email

Phone:*

How did you hear about us? (Please be specific)*

Illinois Professional Licensing Credentials:*

Check all that apply.

Illinois Professional License Number:*

If you are not yet clinically licensed in the state of Illinois, when will you be eligible to take your clinical licensing exam?

Years of experience in this particular field:*

Years of clinical experience working with the populations we serve:*

Have you sent us your resume?*

Thank you for sending your resume! We will review it shortly!

Please send your resume to: application@northshorefamilyservices.com.

What client ages do you have experience treating?*

Check all that apply.

What client ages do you enjoy treating?*

Check all that apply.

What client presenting challenges do you enjoy treating?

Check all that apply.

I enjoy working with:

Check all that apply.

What clients do you prefer NOT to treat and why?*

What does your current/most recent position offer that you also seek in your next position?*

What are you seeking in your next position that your current/most recent position does not offer?*

Please describe any concerns you have about working in a private practice (note examples from previous work settings, if applicable).*

What private practice experience do you have?

Check all that apply.

I have never worked in a private practice.
I currently own my own practice with our without partner(s) and/or employees/independent contractors.
I have owned my own practice with our without partner(s) and/or employees/independent contractors, but do not currently.
I have worked at a private practice as an independent contractor (1099), but do not currently work at that practice.
I have worked at a private practice as an employee, but do not currently work at that practice.
I currently work at a private practice as an independent contractor.
I currently work at a private practice as an employee.

If offered a position at North Shore Family Services, would you prefer to continue owning/working at your current practice or do you anticipate phasing out/leaving your current practice? Why or why not?

Why did you leave private practice previously? And, what has motivated you to consider working at a private practice again?

When working in a clinical capacity, how many clients do you typically see in a week?*

How many clients would you prefer to see in a week?*

Because we serve children, adolescents, and many working adults, our most requested appointment times are weekdays between 3 PM and 8 PM, as well as weekend times. What days/times are you available to work at North Shore Family Services? Please be specific and include days of the week, time frames, and number of client sessions you are seeking for each time period*

Are you able to offer HIPAA-compliant teletherapy sessions?*

Yes
No

Are you able to offer in-office sessions?*

Yes
No

We anticipate continuing to offer both in-office and HIPAA-compliant teletherapy, as we meet the needs and preferences of our clients. Please note your response to this statement. I would prefer to work:

only in-office
only teletherapy
combination of in-office and teletherapy sessions
only teletherapy now, but combination of in-office with teletherapy in the future.

Under what conditions, if any, would you be willing/able to see clients in the office?*

First Choice:*

Second Choice:*

Third Choice:*

Fourth Choice:*

What are your salary requirements (ie. annual salary range and/or per session rate you anticipate)?*

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Email

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Yes. I'm interested in a clinical therapist position at North Shore Family Services!

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