HR Therapist Packet Form

HR THERAPIST PACKET FORM

This packet collects required employment, credentialing, and authorization information for applicants and new therapists. Complete all sections fully and sign where indicated. Incomplete packets may delay consideration or onboarding.

Personal Information

Date of Birth:

Position Information

Expected Start Date:   Desired Employment Status: Full-time Part-time Contract

Licensure, Credentials & Insurance

License Type(s): LCSW LMHC/LPC Psychologist Other

Issuing State:   Expiration Date:

Policy Limits:   Expiration Date:

Clinical Competencies & Practice

Trauma / PTSD Substance Use Children / Adolescents Couples / Family Severe Mental Illness

CBT DBT EMDR Psychodynamic Family Therapy

Yes No   If yes, Supervisor Name:

Employment History (most recent first)

Supervisor:   From:   To:

Supervisor:   From:   To:

Education & Training

Graduation Date:   Field of Study:

Professional References (3 required)

Attachments Checklist

Please indicate documents attached with this packet: Resume / Curriculum Vitae Copy of Current License(s) Proof of Malpractice Insurance Academic Transcripts Relevant Certifications

Legal Disclosures & Authorizations

At-Will Employment: I acknowledge that, if employed, my employment will be on an at-will basis unless otherwise explicitly stated in a separate signed employment agreement. Either I or the employer may terminate the employment relationship at any time, with or without cause or notice.

Equal Opportunity: The employer provides equal employment opportunities to all applicants and employees without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or any other protected characteristic. Reasonable accommodations will be considered in accordance with applicable law.

Background Check and Verification Authorization: I authorize the employer to verify all information provided, and to obtain consumer reports, criminal history, motor vehicle records, licensure verification, and other employment-related information as permitted by law. I understand that adverse information may be grounds for denial of employment or termination.

I consent to background checks, licensure verification and employment reference checks.

Confidentiality & HIPAA: I acknowledge my obligation to maintain client confidentiality and comply with all applicable privacy and confidentiality laws, including requirements concerning protected health information. I agree to adhere to employer policies regarding recordkeeping, disclosure, and client privacy.

Employment Eligibility: I certify that I am eligible to work in this jurisdiction and that I will provide required documentation to establish identity and employment eligibility upon hire.

I certify that all information in this packet is true, accurate, and complete to the best of my knowledge. I understand that falsification or omission may result in denial of employment or termination. I authorize the employer to contact previous employers, education institutions, licensing boards, and references listed in this packet.

Additional Information

Applicant Certification

I certify under penalty of perjury that the information provided in this packet is true, complete, and correct. I understand that any misrepresentation, falsification, or omission of information may disqualify me from employment, or subject me to disciplinary action, up to and including termination. By signing below I consent to the verifications and acknowledgements set forth above.

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