Employee Profile Questionnaire Form

Today's Date:

Expected Start Date:

PERSONAL CONTACT INFORMATION

Please provide your personal contact information for internal company use only.

Full Name:

First

Last

Preferred Alternate First Name:

Personal Phone No.#:

Personal Email Address:

Please provide an alternate personal email address.

Date of Birth:

Primary Mailing Address:

Address Line 1

Address Line 2

City

State

Zip Code

PROFESSIONAL INFORMATION

Please provide detailed professional credentials to promote your therapy specialties and certifications on the company website, business cards, and other advertising materials.

Business Phone No.#:

Business Email:

A HIPAA-compliant company email address will be provided if it hasn't been already (ex: [email protected]).

Specify the therapy session types you will provide to clients.

Specify the mental health disorders and therapeutic modalities you would like to highlight on the website:

To see the mental health disorders and challenges we specialize in, visit the "Therapies" section on our website.

A high-resolution professional headshot is needed for the company website and other advertising. If you don't have one, we can arrange a photo shoot for you.

PHOTO UPLOAD: If you have a high-resolution photo you would like to use, please upload it here.

Click or drag files to this area to upload. You can upload up to 3 files.

You may upload up to three photos if desired.

EDUCATION & EXPERIENCE

Share your education, experience, and mission for your therapist profile.

a.) Educational background and institutions where you obtained your degrees:

b.) List of active certifications and licenses in practice:

Please provide a list of specialized, valid certifications and licenses, using the full names of the certifications.

c.) Outline your prior work history and professional background:

List previous employers along with the duration of employment, highlighting significant contributions or services that demonstrate your expertise.

d.) Describe your personal philosophy and approach to delivering quality therapy services to clients:

Write a brief 2-3 paragraph biography outlining your professional beliefs about therapy services and client support.

e.) Share 2-3 personal details about yourself, such as hobbies or interests, to offer insight into who you are outside of work:

If you have additional information you'd like to include in your therapist profile, such as personal insight, unique approaches, or other relevant details, please share them below:

EMERGENCY CONTACT INFORMATION

For emergency purposes, please provide a contact person whom we can reach if needed.

Contact Full Name:

First

Last

Contact Phone No:#:

Relationship to Contact:

New Employee Profile Form

PERSONAL CONTACT INFORMATION

PROFESSIONAL INFORMATION

EDUCATION & EXPERIENCE

EMERGENCY CONTACT INFORMATION