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Application Information Step 1 of 6 16% Today's Date MM slash DD slash YYYY Full Legal Name(Required) First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneOther PhoneEmail Current Employment (Agency/Company) Position / Title DEGREES HELD AND/OR EXPECTEDPLEASE LIST ANY DEGREES HELD OR EXPECTED DEGREES(Required)INSTITUTIONMAJORDEGREEDATE Add RemoveLICENSURE STATUSPLEASE DETAIL YOUR PRACTICUM PLACEMENT, INTERNSHIP AND OTHER SUPERVISED CLINICAL EXPERIENCE.(Required)LICENSURE TYPESTATEEXPIRATION DATE Add RemovePLEASE LIST ALL AREAS OF COMPETENCY OR PROFESSIONAL PRACTICE FOR WHICH YOU ARE LICENSED OR CERTIFIED.(Required)HAS A LICENSING BOARD, PROFESSIONAL ASSOCIATION OR EDUCATION/TRAINING INSTITUTION EVER TAKEN DISCIPLINARY ACTION OF ANY SORT AGAINST YOU?(Required) Yes No ARE THERE COMPLAINTS PENDING AGAINST YOU BEFORE ANY OF THE ABOVE-NAMED BODIES?(Required) Yes No HAVE YOU EVER HAD A CIVIL SUIT BROUGHT AGAINST YOU RELATIVE TO YOUR PROFESSIONAL WORK OR IS ANY SUCH ACTION PENDING?(Required) Yes No IF YOU ANSWERED “YES” TO ANY OF THE ABOVE, PLEASE EXPLAIN HERE TRAINING AND CLINICALLY RELEVANT EXPERIENCEPLEASE DETAIL YOUR PRACTICUM PLACEMENT, INTERNSHIP AND OTHER SUPERVISED CLINICAL EXPERIENCE.(Required)AGENCY (INCLUDE CLIENT POPULATION/TREATMENT MODALITIES)DATESAPPROXIMATE HOURS Add RemoveRELEVANT JOB EXPERIENCENOTE: In accordance with Minnesota Stature 148 A., we are obliged to contact your employers over the last five years and ask whether they have knowledge of you having sexual contact with clients. Please note that paid internships are considered a form of employment.PLEASE LIST PRESENT AND PAST EMPLOYMENT IN MENTAL HEALTH RELATED SETTINGS INCLUDING PAID INTERNSHIPS FOR AT LEAST THE PAST FIVE YEARS. (Most Recent First)HAVE YOU EVER BEEN ASKED TO RESIGN OR BEEN TERMINATED BY A TRAINING PROGRAM/EMPLOYER?(Required) Yes No DO YOU HAVE EXPERIENCE AS A CLINICAL SUPERVISOR?(Required) Yes No IF YOU ANSWERED “YES” TO ANY OF THE ABOVE, PLEASE EXPLAIN HERE. GENERAL INFORMATIONPLEASE LIST RELEVANT PRESENT AND PAST VOLUNTEER WORK.(Required)PROGRAMACTIVITIESDATE Add RemovePLEASE LIST ANY AREAS OF SPECIAL EXPERTISE.(Required)(i.e. DBT, EMDR, personality disorder counseling, family therapy, foreign language, etc.) YOUR EXPECTATIONSWHY DO YOU WANT TO WORK WITH ROCKBRIDGE?(Required)HOW DID YOU LEARN ABOUT ROCKBRIDGE?(Required)WHAT DO YOU EXPECT FROM THIS POSITION?(Required)WHAT IS YOUR PREFERRED NUMBER OF HOURS?(Required)WHAT IS YOUR PREFERRED ESTIMATED START DATE?(Required) MM slash DD slash YYYY REFERENCESPLEASE LIST THE NAMES, AGENCY/INSTITUTIONS; AFFILIATIONS AND PHONE NUMBERS OF THREE PEOPLE WHO ARE FAMILIAR WITH OR WHO HAVE SUPERVISED YOUR CLINICAL WORK WITHIN THE LAST FIVE YEARS.(Required)NAMEAGENCY/INSTITUTIONPHONE Add RemoveSTATEMENT OF APPLICATIONPLEASE READ THE FOLLOWING CAREFULLY.(Required) By checking this box, I agree to the privacy policy.All information submitted by in this application is true to the best of my knowledge. I understand that any significant misstatement in, or omission from, this application may be cause for denial of appointment as an independent contractor or cause for dismissal from the position at Rockbridge. By applying for a position with Rockbridge, I acknowledge that I have the responsibility to read, understand and act in accordance with all ethical and legal guidelines outlined by the organizations associated with and monitoring your license to practice, Rockbridge policies and peer review procedures. I authorize Rockbridge to consult with persons or institutions with which I have been associated and with others, including past and present employers, who may have information bearing on my professional competence, character, and ethical qualifications. I understand and agree that I will notify Rockbridge of any changes in my job or training status, licensure, censure or sanction by professional bodies, or any other information relating to my ability to perform as an employee of Rockbridge.RESUME UPLOAD(Required)Accepted file types: pdf, txt, doc, docx, odt, ott, , Max. file size: 30 MB.ADD A COVER LETTER(Required)Accepted file types: pdf, txt, doc, docx, odt, ott, , Max. file size: 30 MB.
