Pine Rest Christian Mental Health Services - Preliminary Application for Employment

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Opportunities for

•		Employment
•		Internships
•		Volunteers

Application for Employment

Please fill out the following form as completely as possible.
Items in red are required.


Personal Information

First Name:
Middle Name:
Last Name:

Last four digits of your Social Security No:
Other names used for school or other employment:

Email Address:

Address:
City:
State:
Zip:
Home Phone:
Other Phone (Mobile):

Position Desired:
Other:

Referred by:

What interested you in seeking employment at Pine Rest?

Days Available to work:	Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Status Preferred:	Full Time Part Time On Call

Shift Preferred:	Day Evening Night

Have you ever been employed at Pine Rest in the past?	Yes No
If "Yes", when?

Are you at least 18 years of age?	Yes No

Do you have legal authorization to work in the United States?	Yes No

Have you ever been convicted of a crime, or have any felony charges pending against you?	Yes No
If "Yes", please explain:

Are you willing to take a pre-employment physical exam including a test for current use of illegal drugs upon being offered a job at Pine Rest?	Yes No



Professional Registration, License, or Certification

1)
State:
Registration Number:
Dates:
Type:

2)
State:
Registration Number:
Dates:
Type:

3)
State:
Registration Number:
Dates:
Type:

Are you currently or have you ever been subject to disciplinary action by any federal or state licensure / certification board?
	Yes No
If "Yes", please explain.


Employment History

List below all present and past employers, beginning with your most recent. All sections must be completed.

May we contact your current & previous employers?	Yes No

Employer:
Address:
City:
State:
Zip:
Supervisor:
Phone:
Position:
Start Date:
End Date:
Salary Upon Leaving:
Reason for Leaving:
Responsibilities:

Employer:
Address:
City:
State:
Zip:
Supervisor:
Phone:
Position:
Start Date:
End Date:
Salary Upon Leaving:
Reason for Leaving:
Responsibilities:

Employer:
Address:
City:
State:
Zip:
Supervisor:
Phone:
Position:
Start Date:
End Date:
Salary Upon Leaving:
Reason for Leaving:
Responsibilities:


Professional Affiliations

List participation in school, civic, community, or special interest groups, and any offices held (exclude any organization for which the name or character of which would reveal race, religion, national origin, disability, and political affiliations).

1) Please list the organization name, the position you held, and your responsibilities:
2) Please list the organization name, the position you held, and your responsibilities:
3) Please list the organization name, the position you held, and your responsibilities:
4) Please list the organization name, the position you held, and your responsibilities:

References

Please list any references that may be in addition to the employers listed above. Do not include relatives or former employers. * For clinical staff, must provide three peer references.

Name:
Relationship to Applicant:
Business:
Address:
City:
State:
Zip:
Phone:

Name:
Relationship to Applicant:
Business:
Address:
City:
State:
Zip:
Phone:

Name:
Relationship to Applicant:
Business:
Address:
City:
State:
Zip:
Phone:


Education

Did you graduate from High School?	Yes No

Did you receive an Associate’s degree?	Yes No Still Attending
Name of College:
State degree received/pursuing:

Did you receive a Bachelor’s degree?	Yes No Still Attending
Name of College:
State degree received/pursuing:
State Major / Minor. Be specific:

Did you receive a Master’s degree?	Yes No Still Attending
Name of College:
State degree received/pursuing:
State Major / Minor. Be specific:

Did you receive a Doctoral degree?	Yes No Still Attending
Name of College:
State degree received/pursuing:
State Major / Minor. Be specific:

Did you perform an Internship?	Yes No

Any additional training you would like to indicate	Yes No
Please explain:

Please indicate any additional skills, training, computer proficiency, interests, volunteer experiences or organizational memberships: (i.e. foreign language, safety training, professional memberships or affiliations etc.)



Request for Privileges

I hereby apply for the following delineated privileges. If requesting child privileges please provide evidence of training and/or experience.

Psychology	For Assessment & Treatment of: Adolescent/Adult/Geriatric Patients Child Patients
Social Work	For Assessment & Treatment of: Adolescent/Adult/Geriatric Patients Child Patients

List clinical areas of expertise:
	Adjustment Disorders Adoption Anger Management Anxiety Disorders Autism Spectrum Disorders Co-Dependency Issues Co-Occurring Mental Health and Substance Use Disorders Coping with Chronic Medical Illness Developmental Disabilities Early Childhood Eating Disorders ECT Evaluation - Learning Disabilities, ADD, ADHD Evaluation - Neurological Evaluation - Pre-Surgical Evaluation - Psychiatric Evaluation - Return to Work Evaluations – Substance Use Disorders Gambling Grief and Loss Counseling Marital Counseling Men's Issues Mental Retardation Mood Disorders, Depression OCD Older Adults, Gerontology Parent/Child Conflicts Personality Disorders – DBT PTSD School Adjustment Conflicts Self-Injury Sexual Addiction Sexual and Gender Identity Disorders Sexual Dysfunction Spiritual Issues Substance Use Disorders Women's Issues


Computer Proficiency

Indicate which of the following programs you are proficient at:	Microsoft Windows Microsoft Outlook Microsoft Excel Microsoft Word Cerner Healthquest Other


Additional Comments



Applicant’s Certification and Agreement

PLEASE READ CAREFULLY: 1. Certification of Truthfulness. I certify that all statements on this Application for Employment are complete and truthful and agree that such statements may be investigated and if found to be false will be sufficient reason for not being employed, or if employed may result in my dismissal. 2. Authorization for Employment/Educational Information. I authorize the references listed in this Application for Employment, and any prior employer, educational institution, or any other persons or organizations to give Pine Rest any and all information concerning my previous employment/educational accomplishments, disciplinary information or any other pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I hereby waive written notice that employment information is being provided by any person or organization. 3. Authorization to Work. If I am selected for hire, I will be offered employment provided I verify that I am authorized to work as required by the Immigration Reform and Control Act of 1986. 4. Limitation on Claims. I agree that any lawsuit or claim against Pine Rest arising out of my employment or termination of employment (including, but not limited to, claims arising under state, federal or local civil rights laws) must be brought within the following time limits or be forever barred: (a) for lawsuits requiring a Notice of Right to Sue from the EEOC, within 90 days after the EEOC issues that Notice; or (b) for all other lawsuits, within (i) 180 days of the event(s) giving rise to the claim, or (ii) the time limit specified by statute, whichever is shorter. I waive any statute of limitations that exceeds this time limit. 5. Need for Accommodation. If I have a mental or physical disability and require an accommodation to perform the job, I must notify Pine Rest of that need in writing within 182 days after I knew or reasonably should have known that an accommodation was needed. Failure to do so will bar me from alleging that Pine Rest has not accommodated me as required by law. 6. Criminal Records Check. I authorize Pine Rest to secure my criminal conviction history. I agree to execute the appropriate authorization if necessary to obtain such information. 7. Driving Record Check. I agree to execute an authorization for Pine Rest to inquire into, and obtain documents related to, any driving record from every state in which I have held a motor vehicle operator’s license or permit. Clinicians Only: I am responsible for producing adequate information for proper evaluation of my credentials. I certify that I am currently physically and mentally able to perform the privileges I am requesting with or without accommodations.


I have read, and I agree to the above terms.
	(Type "Yes" if you agree.)
Name:
Today's Date:



Click the Submit button only once. It may take up to one minute to send your application.

Human Resources
Pine Rest Christian Mental Health Services
300 68th Street SE
PO Box 165
Grand Rapids, MI 49501
616-455-4290
Fax: 616-831-2608