Application Form Step 1 of 13 7% X/TwitterThis field is for validation purposes and should be left unchanged.Thank you for completing our application! You will have the opportunity to upload your resume and other application materials (up to 2 files) before you submit the form. If you are unable to complete the application in one session, scroll to the bottom of any page and click "Save and Continue Later." You will see a unique link where you can complete your application within 30 days. Basic InformationPosition Applied ForAre you licensed or license eligible through the Virginia Board of Counseling?* LPC LCSW LMFT Resident in Counseling Resident in Social Work Resident in Marriage & Family Counseling None Please enter your NPI number and license number.*Name* First Last Address* Street Address Apt Number (if applicable) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*SMS Opt-in By checking this box, I agree to receive informational SMS messages from Southside Behavioral Health at the phone number provided above. The SMS frequency may vary. Data rates may apply. Reply HELP for assistance. Reply STOP to opt out of receiving SMS messages, please refer to our privacy policy: https://southsidebh.org/privacyEmail Enter Email Confirm Email How did you find out about this position?Social mediaSouthside Behavioral Health WebsiteVirginia Employment Commission websiteOther online job listings (Indeed, LinkedIn, etc.)Newspaper ad EducationSchools Attended*Please enter institutions attended beginning with high school To add additional institutions, click on the plus sign at the end of each line. School AttendedYears CompletedDiploma/DegreeMajor Trainings and CertificationsPlease list additional skills, qualifications, certifications, or licenses. Employment StatusHave you ever worked for Southside Behavioral Health?* Yes No When did you work for us?*Are you currently employed?* Yes No May we contact your present and/or past employer?* Yes No On what date will you be available for work?* Are you able to work:*(Check all that apply.) Full-time Part-time Shift work Are you currently on lay-off status and subject to recall?* Yes No Are you willing to accept employment that requires travel?* Yes No Are you prevented from lawfully becoming employed in this country because of visa or immigration status?* Yes No ReferencesReferences*Please list at least three references. Click on the plus sign at the end of the line to add entries.NameRelationshipAddressPhone number Employment HistoryEmployer Name**Start DateEnd DateJob Title*Name of Supervisor*Employer Address*Employer Phone*Major Responsibilities*Reason for Leaving*Add another job?* Yes, please. No, I'm finished. Employment HistoryEmployer Name**Start DateEnd DateJob Title*Name of Supervisor*Employer Address*Employer Phone*Major Responsibilities*Reason for Leaving*Add another job?* Yes, please. No, I'm finished. Employment HistoryEmployer Name**Start DateEnd DateJob Title*Name of Supervisor*Employer Address*Employer Phone*Major Responsibilities*If you have other jobs to tell us about, you'll have a chance to upload a resume at the end of this application. Do you speak a foreign language?* Yes No If yes, please specify.*Rate Your Ability*BeginnerIntermediateFluentDo you use American Sign Language?* Yes No Rate Your Ability*BeginnerIntermediateFluent Criminal HistoryHave you ever been convicted of a law violation(s), including moving traffic violations, but excluding offenses before your 18th birthday?* Yes No Please Provide Details of law violations*Have you ever had allegations made against you of client abuse?* Yes No Please provide details of client abuse allegations*Have you ever been convicted of a criminal violation involving drugs and/or alcohol abuse?* Yes No Please provide details of criminal violation*Are you currently a participant in any allegation(s) relating to law violations involving drug and/or alcohol abuse?* Yes No Please provide details of law violation allegations*Are you currently involved as a client in an active treatment program for drug/alcohol abuse?* Yes No What supportive reasonable accommodation needs will you require of SBH as they relate to your successful completion of the substance abuse treatment program? Applicant Signature*By typing my name below, I hereby certify that all entries in this application are true and complete, and I agree and understand that any falsification of information herein, regardless of the time of discovery, may cause forfeiture of my employment. I understand that all information on this application is subject to verification and I consent to references and former employers and educational institutions listed being contacted regarding this application. First Last Signature Date* Please be advised that the information you have provided on this supplemental information form will remain confidential in accordance with the provisions of the Privacy Protection Act and will not be used to discriminate in making an employment decision as applicable under Civil Rights Legislation.Applicant Signature*By typing my name below, I certify that the information provided in response to the questions related to SBH’s compliance with the Drug Free Work Act is complete and accurate. First Last Signature Date* EEO-1 Self-Identification FormThe employer is subject to certain governmental record keeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.GenderAre you Hispanic or Latino? Yes No What is your race (if you are not Hispanic or Latino as indicated above)?Are you a military veteran? Yes No Other Application MaterialsPlease upload your resume or other application materials. Drop files here or Select files Max. file size: 256 MB, Max. files: 2. Δ
