ERHC Mental Health Provider Candidate Questionnaire

For mental health provider applicants only

OPPORTUNITY: Mental Health Therapist

Thank you for your interest in Emergency Responders Health Center!

Please take a moment to complete this brief candidate questionnaire, and upload a PDF of your (i) current CV and (ii) cover letter in the space provided. If you experience any difficulties uploading your documents, please reach out to us at the email below.

You may direct any questions to our administrative staff at wellness@er-hc.org.

We will confirm receipt of your application within (5) business days.

Important: This application portal is for use by mental health professional candidates only. All other job-seekers are encouraged to view the ERHC Careers page found at er-hc.org, for a list of any non-therapist openings. Only qualified applicants will receive a response to their submission. This application portal was created using a HIPAA-compliant web-based software application.

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* 1. Last Name

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* 2. First Name

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* 3. Contact Information

Street Address

Unit Number

City

State

ZIP Code

Preferred Email Address

Preferred Phone Number

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* 4. Licensure

LCSW

LCPC

LMFT

Other (please specify)

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* 5. Enter your years of clinical practice in mental health care.

< 2

2 to 3

4 to 9

> 10

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* 6. I am licensed to practice therapy in the following states:

State

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* 7. Practice Locations
(Please select all that apply.)

I currently practice in southwestern Idaho.
(i.e., Boise, Meridian, Nampa, or surrounding communities)

I currently practice in northern Idaho or northeastern Washington.
(i.e., Coeur d'Alene, Spokane, or surrounding communities)

I am interested in relocating to southwestern Idaho.

I am interested in relocating to northern Idaho or northeastern Washington.

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* 8. Desired Employment
(Please select all that apply.)

I am seeking a full-time, employed position.

I am seeking a part-time, employed position.

I am seeking a contract position.

I am seeking referrals to my existing private practice.

Other (please describe your desired engagement with ERHC)

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* 9. Please describe your experience in delivering trauma-informed care, or treating PTSI/PTSD, including specific certifications and treatment modalities.

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* 10. Please list all other active certifications.

Certification/
Last Year Conferred
or Renewed:

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* 11. Please select those conditions for which you have direct clinical experience, ranking the degree of your expertise from preliminary to extensive.
(For areas where you have no expertise to report, please leave blank.)

	(1) Preliminary Experience	(2) Moderate Experience	(3) Extensive Experience
Anxiety & Depression	Anxiety & Depression (1) Preliminary Experience	Anxiety & Depression (2) Moderate Experience	Anxiety & Depression (3) Extensive Experience
Grief & Loss	Grief & Loss (1) Preliminary Experience	Grief & Loss (2) Moderate Experience	Grief & Loss (3) Extensive Experience
Trauma & PTSI/PTSD	Trauma & PTSI/PTSD (1) Preliminary Experience	Trauma & PTSI/PTSD (2) Moderate Experience	Trauma & PTSI/PTSD (3) Extensive Experience
Substance Abuse	Substance Abuse (1) Preliminary Experience	Substance Abuse (2) Moderate Experience	Substance Abuse (3) Extensive Experience
Suicidality	Suicidality (1) Preliminary Experience	Suicidality (2) Moderate Experience	Suicidality (3) Extensive Experience
Alcohol/Substance Dependency	Alcohol/Substance Dependency (1) Preliminary Experience	Alcohol/Substance Dependency (2) Moderate Experience	Alcohol/Substance Dependency (3) Extensive Experience

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* 12. Please select those services for which you have direct experience, ranking the degree of your expertise from preliminary to extensive.
(For areas where you have no experience to report, please leave blank.)

	(1) Preliminary Experience	(2) Moderate Experience	(3) Extensive Experience
Mental/Behavioral Health Screening	Mental/Behavioral Health Screening (1) Preliminary Experience	Mental/Behavioral Health Screening (2) Moderate Experience	Mental/Behavioral Health Screening (3) Extensive Experience
Individual Therapy	Individual Therapy (1) Preliminary Experience	Individual Therapy (2) Moderate Experience	Individual Therapy (3) Extensive Experience
Couple's Therapy	Couple's Therapy (1) Preliminary Experience	Couple's Therapy (2) Moderate Experience	Couple's Therapy (3) Extensive Experience
Family Therapy	Family Therapy (1) Preliminary Experience	Family Therapy (2) Moderate Experience	Family Therapy (3) Extensive Experience
Support Group Facilitation	Support Group Facilitation (1) Preliminary Experience	Support Group Facilitation (2) Moderate Experience	Support Group Facilitation (3) Extensive Experience
Outreach Presentations/Education	Outreach Presentations/Education (1) Preliminary Experience	Outreach Presentations/Education (2) Moderate Experience	Outreach Presentations/Education (3) Extensive Experience

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* 13. What are the primary treatment types/modalities you offer?

Treatment Type

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* 14. Which clients do you see?
(Select all that apply.)

Children

Adolescents

Adults

Adults - Seniors/Retirees

Individuals

Couples

Families

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* 15. With regard to Telehealth mental health service delivery, please select any statements that apply to your practice.
(Please leave blank if no statements apply.)

I have experience practicing therapy via Telehealth applications.

I am interested in practicing therapy via Telehealth applications.

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* 16. Please use the space below to provide additional comments with regard to the primary conditions you treat and the clinical services you offer.

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* 17. Please briefly describe any relevant prior experience in caring for, or working alongside, first responder* populations.
(*Firefighters, law enforcement officers, paramedics/EMTs, dispatchers, military responders, etc.)

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* 18. How did you learn about this practice opportunity?
(Please use the open comment field to list the exact location of the posting.)

National or State Job Board Posting (online) - Please list specific outlet below.

Professional Association Posting (online) - Please list specific outlet below.

ERHC Careers Page (er-hc.org or erhcnorth.org)

Personal Referral - Please list specific contact below.

Other Social Media

Direct Mail Piece

Other (please describe below)

Please list the specific outlet(s) where you saw this practice opportunity posted, and/or the individual(s) who referred you to ERHC.

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* 19. Use this space to upload a current CV as a PDF.
(If you experience challenges, email us at wellness@er-hc.org.)

PDF file types only.

Choose File

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* 20. Use this space to upload a cover letter as a PDF.
(If you experience challenges, email us at wellness@er-hc.org.)

PDF file types only.

Choose File

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* 21. Please use the space below to provide any additional comments that you'd like to share with our hiring team.

Thank you again for your interest in ERHC!

ERHC Mental Health Provider Candidate Questionnaire

For mental health provider applicants only

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* 1. Last Name

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* 2. First Name

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* 3. Contact Information

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* 4. Licensure

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* 5. Enter your years of clinical practice in mental health care.

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* 6. I am licensed to practice therapy in the following states:

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* 7. Practice Locations (Please select all that apply.)

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* 8. Desired Employment(Please select all that apply.)

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* 9. Please describe your experience in delivering trauma-informed care, or treating PTSI/PTSD, including specific certifications and treatment modalities.

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* 10. Please list all other active certifications.

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* 11. Please select those conditions for which you have direct clinical experience, ranking the degree of your expertise from preliminary to extensive. (For areas where you have no expertise to report, please leave blank.)

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* 12. Please select those services for which you have direct experience, ranking the degree of your expertise from preliminary to extensive. (For areas where you have no experience to report, please leave blank.)

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* 13. What are the primary treatment types/modalities you offer?

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* 14. Which clients do you see?(Select all that apply.)

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* 15. With regard to Telehealth mental health service delivery, please select any statements that apply to your practice.(Please leave blank if no statements apply.)

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* 16. Please use the space below to provide additional comments with regard to the primary conditions you treat and the clinical services you offer.

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* 17. Please briefly describe any relevant prior experience in caring for, or working alongside, first responder* populations.(*Firefighters, law enforcement officers, paramedics/EMTs, dispatchers, military responders, etc.)

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* 18. How did you learn about this practice opportunity?(Please use the open comment field to list the exact location of the posting.)

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* 19. Use this space to upload a current CV as a PDF.(If you experience challenges, email us at wellness@er-hc.org.)

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* 20. Use this space to upload a cover letter as a PDF.(If you experience challenges, email us at wellness@er-hc.org.)

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* 21. Please use the space below to provide any additional comments that you'd like to share with our hiring team.Thank you again for your interest in ERHC!

* 7. Practice Locations
(Please select all that apply.)

* 8. Desired Employment
(Please select all that apply.)

* 11. Please select those conditions for which you have direct clinical experience, ranking the degree of your expertise from preliminary to extensive.
(For areas where you have no expertise to report, please leave blank.)

* 12. Please select those services for which you have direct experience, ranking the degree of your expertise from preliminary to extensive.
(For areas where you have no experience to report, please leave blank.)

* 14. Which clients do you see?
(Select all that apply.)

* 15. With regard to Telehealth mental health service delivery, please select any statements that apply to your practice.
(Please leave blank if no statements apply.)

* 17. Please briefly describe any relevant prior experience in caring for, or working alongside, first responder* populations.
(*Firefighters, law enforcement officers, paramedics/EMTs, dispatchers, military responders, etc.)

* 18. How did you learn about this practice opportunity?
(Please use the open comment field to list the exact location of the posting.)

* 19. Use this space to upload a current CV as a PDF.
(If you experience challenges, email us at wellness@er-hc.org.)

* 20. Use this space to upload a cover letter as a PDF.
(If you experience challenges, email us at wellness@er-hc.org.)

* 21. Please use the space below to provide any additional comments that you'd like to share with our hiring team.

Thank you again for your interest in ERHC!