PLEASE READ THIS BEFORE YOU COMPLETE YOUR APPLICATION FOR EMPLOYMENT *

1. Please understand that completing the “Application for Employment” is not a guarantee of employment. This document is part of the Employment Application and our hiring process. 2. The application must be completely filled out to be accepted and considered. 3. Do not write “See Resume” in any section! This application is a legal document and must be fully completed and signed 4. All information on the Application for Employment must be true and complete to the best of your knowledge and, if employed, the discovery of falsified statements on this application shall be grounds for dismissal. 5. Reference information is important and required! If references and/or information on this application cannot be verified, you will not be considered for employment. 6. If you should be hired before required testing, reference checking, and verification of the information you have provided is completed, be aware that continued employment will be subject to “satisfactory results”. 7. All positions are “At Will”, meaning that there is never a guarantee of continued employment for any specific period of time unless a separate and special written agreement has been entered into. 8. I release the Company and its officers, manager, and representatives from any liability for the conducting of pre-employment tests, etc. and the reliance of the results of these tests in reaching a decision related to my employment. I certify that I read and understand this information. I authorize the investigation and verification of all statements and references contained in the attached “Application for Employment” in order to be considered for employment.

I read and understand this information.

Position Applying For: *

Applicant can select more than one:

Licensed Therapist (Part Time)

Contractor Therapist

Clinical Supervisor

Name *

First Name

Last Name

D.O.B *

Date of Birth

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

1. Have you ever been convicted of a felony or have charges pending for a felony? *

YES

NO

2. Have you ever lost or had your licensure suspended? *

YES

NO

5. If Applicant has LAC or LSW, do you have a Clinical Supervisor? *

YES

NO

n/a

6. Are you open to conducing Virtual Sessions? *

Yes

No

n/a

Reference 1 *

First Name

Last Name

Phone *

(###)

###

####

Reference 2: *

First Name

Last Name

Phone *

(###)

###

####

Reference 3: *

First Name

Last Name

Phone *

(###)

###

####

Send Resume to Todd@Elitementalwellness.com *

Before submitting your application please send Resume to email above:

Resume Sent

PLEASE READ CAREFULLY BEFORE SIGNING: *

In consideration of employment Elite Mental Wellness, I agree to abide by the rules and regulations of the company, which may be changed from time to time at the sole discretion of company management. I declare each of the answers I have given in this employment application to be complete and true to the best of my knowledge. I understand that any false information or omissions may disqualify me from further consideration for employment and may result in my discharge from employment if discovered at a later date. It is the policy of Elite Mental Wellness that all qualified applicants are given equal opportunity and that selection decisions be based on job-related factors. We abide by ALL City, State & Federal employment regulations that apply to the company. No question on this application is used for the purpose of excluding any applicant for employment. I agree to inform Elite Mental Wellness if I require reasonable accommodation for the application and/or interview process. I understand that as a condition of employment I must be authorized to work in the United States and demonstrate that authorization as required by Immigration Reform and Control Act of 1986. I authorize the investigation of all statements contained in this application and authorize any person, school, current employer (unless otherwise noted), past employers and other organizations named in this application to provide relevant information that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand that some positions may require Drug Tests, Criminal Background Checks, and other position related background checks. I understand that this application or subsequent employment does not create an employment contract nor guarantee employment for any defined period of time. I also understand that this employment application is not valid unless completely filled out. Further, I understand that my employment is “at-will” and can be terminated by either Elite Mental Wellness or me at any time for any reason or for no reason.

I have read and understand