Licensed Therapist

Date of application*

Position Applying For:*

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Illinois Credentials (ie. LSW, LCSW, LPC, LCPC, ALMFT, LMFT, PsyD, PhD)*

Illinois License Number:*

If you are not yet clinically licensed in the state of Illinois (ie. LCSW, LCPC, LMFT, PsyD, PhD), when will you be eligible to take your clinical llicensing exam?*

Years of experience in this particular field*

Years of clinical experience working with the population we serve*

How Did You Hear About Us?*

Please be specific. Choose all that apply.

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 is your experience with working in a private practice?*

Why are you interested in working for a group practice rather than, or in addition to, your own practice? If you currently have your own practice, with or without associates, do you anticipate continuing to work in your own practice while working in a group practice? Why/Why Not?*

How do you know you have developed rapport with your clients in the first session?*

Why are you interested in working at North Shore Family Services? Please include at least two benefits you anticipate/have experienced from working in a private practice.*

Describe your ideal client (provide detail to age range, client issues/struggles)*

What kinds of clients do you prefer NOT to work with and why?*

Please describe any concerns you may have about working in a private practice. Please note examples from previous work settings, when possible.*

Tell us how you have encouraged children, engaged teens, and empowered families. Please give specific examples of clinical work (without giving PHI).*

Which location would you prefer? Note: If you are applying to work at only one specific location, you may repeat your first choice throughout the list. Then, you will only be considered for a position at that specific location should there be an appropriate opening.*

First Choice

Second Choice*

Third Choice*

Fourth Choice*

Because our practice serves children, adolescents, and many working adults, our most requested appointment times are after school, evening, and weekend hours. What days/times are you available to work at North Shore Family Services? Please be specific (include days of the week, time frames, minimum/maximum number of client session hours you are seeking).*

Are you able to offer in-office sessions?*

Yes
No

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

Yes
No

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