Apply for Behavioral Health Clinician

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.
Please complete the employment history information even if you are attaching a resume.

Summary
Title:Behavioral Health Clinician
ID:1194
Department:Behavioral Health
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
* Social Security #:
Attachments
Resume:
Supported formats: Word, PDF, RTF, Text, and HTML.
  - or Upload from:
 
Cover Letter:
You can type in a Cover Letter or Copy/Paste from an existing document.
Application for Employment
PERSONAL INFORMATION
* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):
Yes   No
* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):
Yes   No
* Have you ever worked for this Company before?:
Yes   No
If Yes, please provide details (Where/When/Job Title):
* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:
Yes   No

EMPLOYMENT DESIRED
* When would you be available to begin work?:
* Type of employment desired:
Full-Time
Part Time
Seasonal
* Hourly rate/salary desired:
* Are you currently employed?:
Yes   No
If so may we inquire of your present employer?:
Yes   No
If presently employed, why are you considering leaving?:

EDUCATION
Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location Did you Graduate? Degree Received Subjects Studied/Major
*
*
Yes   No
*
*
Yes   No
Yes   No

If you have completed any special courses, seminars and/or training that would help you to perform the position for which you are applying, please describe:

EMPLOYMENT HISTORY
Give your full employment record, starting with your current or most recent employment

PLEASE COMPLETE THE EMPLOYMENT SECTION EVEN IF YOU HAVE UPLOADED A RESUME.

EMPLOYER 1

Dates Employed Employer Name & Address Employer Phone
From:
*

To:
*
*

*
*
Job Title Supervisor Name & Title May we Contact?
*
*

*
*
Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
*
*
Start:
*

End:
*

EMPLOYER 2

Dates Employed Employer Name & Address Employer Phone
From:

To:
Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

EMPLOYER 3

Dates Employed Employer Name & Address Employer Phone
From:

To:
Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

REFERENCES Please provide three references (not relatives).

Name Relationship Phone Number Email
*
*
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*
*
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AUTHORIZATION
The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name):
* Date:
Criminal Background
CRIMINAL BACKGROUND INFORMATION PLEASE READ BEFORE ANSWERING THE QUESTIONS BELOW: * A criminal conviction may involve, but is not limited to, incarceration, confinement, fines, suspended sentence or other penalties assessed by the courts. * A conviction may not necessarily disqualify an applicant from employment, however, there are specific State guidelines we must follow due to the population we serve. (see Ohio Revised Code) * Failure to provide complete information on the application may result in termination of employment. All new hires are finger printed.
* Have you ever pled guilty, no contest, or been convicted of a misdemeanor or felony crime?
Yes   No
* Do you have a criminal record that has been sealed? (Sealed records are provided to Blick Clinic because we provide services to individuals with disabilities)
Yes   No
If you answered "Yes" to either question above, please describe in full below.  Provide dates, conviction, and description of the incident.  "Will explain in the interview" is not an acceptable answer.
Authorization for release and use of consumer rerports
Please read the following:
* AUTHORIZATION FOR RELEASE AND USE OF CONSUMER REPORTS
   
As part of purposes, including promotion, transfer, or retention during the term of my employment, I understand that a criminal records check, motor vehicle records check, and/or other consumer reports may be obtained by The Blick Center.  
 
I understand that a Consumer Reporting Agency may not give out information about me without my written consent.  I understand that no report containing medical information about me will be provided to The Blick Center without my specific prior consent releasing such information which is in addition to my general authorization, below.
   
I hereby authorize The Blick Center to request reports from the Ohio Bureau of Criminal Identification and Investigation, the Ohio Bureau of Motor Vehicles, and other Consumer Reporting Agencies to be used for employment related purposes, including hiring, promotion, transfer, or retention now or in the future.
   
I hereby authorize and request that any present or former employer, school, police department, financial institution, or other person having information or knowledge about me, furnish such information to the bearer of this authorization in connection with an application for employment.
   
I agree to release and discharge The Blick Center, its employees, officers, agents, affiliates, and shareholders from any and all claims, rights of action or liability of any kind or nature that could result from The Blick Center's use or reliance upon the information contained in such consumer reports.

NOTICE OF USE OF CONSUMER REPORTS
   
Ohio law requires The Blick Center to fingerprint employees for the Ohio Bureau of Criminal Identification and Investigation to perform a criminal records check.  If you have lived outside of the State of Ohio, you must also obtain an FBI background check.  In addition to the criminal records check, The Blick Center may obtain consumer reports from a Consumer Reporting Agency as part of its procedure for processing your employment application and/or for other employment processes, including promotion, transfer, or retention during your employment.  The Blick Center typically only requests consumer reports which provide information regarding criminal records and motor vehicle records; however, The Blick Center may also request a consumer report that includes information regarding your credit, character, general reputation, personal characteristics, and mode of living.
   
The Blick Center will not obtain information from a Consumer Reporting Agency without your written permission.
Yes   No

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