Clinical Therapist Application

Let’s work together.

Thank you for your interest in Anomaly Therapy. Please fill out this application and acknowledge the information is correct and true. Please note, for your application to be considered, you must submit your completed application form and the clinical therapist questionnaire. If you have any questions, please email Jessica Mansell at jess@anomalytherapy.com. Thank you and we look forward to connecting.

Personal Information

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pronouns

Are you fluent in any languages other than English? If yes, explain.

Education

Graduate Education

Please list your University, Graduate Program, and Graduation Date

Undergraduate Education

Please list your University, Degree, and Graduation Date

CLINICAL EXPERIENCE AND CERTIFICATIONS

Please list any trainings and formal certifications

Please provide any previous clinical experience, internship placements, or relevant volunteer work.

If you have previous clinical experience, please provide the location, dates worked, supervisor and a brief description of responsibilities.

What is your ideal population or preferred niche?

Please provide who you know you like to work with and who you prefer to refer out.

What is your approach to working with clients?

Please describe your approach to counseling (theoretical orientation, clinical approach, etc.)

Do you have an active caseload?

Are you interested in hosting a group?

SKILLS ASSESSMENT

List any skills or qualities that you have to offer that will be beneficial in your work at Anomaly Therapy

List three things you hope to gain from your work at Anomaly Therapy

Please list an area of growth - something you are aware needs improvement - that you would like to address

Please briefly describe your professional goals in clinical mental health counseling.

Have you ever been charged or convicted of any felonies or ethical violations?

Yes

Do you have an interest of one day opening your own practice?

Is there anything else you would like us to know?

References

Please list 2 professional references and their contact information.

Reference 1

First Name

Last Name

Reference 2

First Name

Last Name

Statement of Accuracy and Authorization

This form has been completed to the best of my ability, and I believe all answers to be true and factual. I understand that any false information or omission may disqualify me from further consideration if discovered at a later date.

First Name

Last Name

Date

YYYY

Let’s work together.

a n o m a l y t h e r a p y