Independent Contractor Application

Responsibilities:

Will develop a treatment plan for clients based upon an initial intake evaluation, any previous clinical experience, and contractor’s knowledge.
Will adjust a client’s treatment plan to take into account changes in a client’s situation or status.
Expected to maintain secure and confidential records regarding the client’s treatment plan.
Provides clinical services either through telehealth or with in-person sessions.
Will gather information on mental health resources that could be used the aid a client’s treatment plan.
Will be an advocate for clients to coordinate necessary services or resolve emergency problems that could occur in a crisis.
Is expected to complete and maintain documentation that meets established federal, state, and insurance guidelines.
Will maintain compliance with federal and state laws regarding HIPPA and mandated reporting.

Qualifications:

Exhibits good verbal and written communication skills.
Is able to establish and maintain a good relationship with clients.
Must maintain professional liability insurance for the duration of the contract.
Must maintain a minimum of 10 clients.
License and previous experience is preferred but supervision can be provided for those seeking their license and need supervision.

Apply Here!

Please send your resume to christy@sustaininggraceconsulting.com and fill out the form below.

Application

Personal Information

Name

First Name

Last Name

Phone number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Job Information

Years of relevant job experience

Desired number of clinical hours per week?

How did you hear about us?

Have you ever worked in a private practice?

Yes

Are you currently credentialed with any insurances? if yes, then please list them:

Education

Name of Graduate School

Major

Degree

Graduation Date

YYYY

License Information

License Number

Issuing State

Issued Date

YYYY

Expiration Date

YYYY

License Type

Is your license or certification currently under investigation?

Yes

If yes, then please describe why it is being investigated:

Work Experience

Please list your work experience for the last 5 years starting from most recent for up to 3 positions.

Company Name

Job Title

Start Date

YYYY

End Date

YYYY

Company Name

Job Title

Start Date

YYYY

End Date

YYYY

Company Name

Job Title

Start Date

YYYY

End Date

YYYY

References

Name

First Name

Last Name

Current Position

Company Name

Phone

(###)

###

####

Name

First Name

Last Name

Current Position

Company Name

Phone

(###)

###

####

Name

First Name

Last Name

Current Position

Company Name

Phone

(###)

###

####

Please read through the following section carefully before submitting

I certify and attest that all of the information submitted by me in my Application and in any requested supplemental forms is both true and correct. I also understand that any false, misleading statements, or information that was willfully omitted, on this Application or any other supplemental forms can be sufficient evidence for the disqualification of my Application or, if it were discovered after a contractual agreement is made, can result in immediate termination of my contract.

Please initial

I understand that no policy, benefit, or practice established by Sustaining Grace Consulting creates a binding obligation by Sustaining Grace Consulting, and that these policies, benefits, or practices could be changed by Sustaining Grace Consulting at any time and in its sole discretion.

Please initial

I understand that Sustaining Grace Consulting, complies with the provisions in the Drug-Free Workplace Act of 1988. The unlawful manufacturing, dispensing, distribution, possession, or usage of these controlled substances (also often referred to as 'illegal drugs' as listed in the Federal Controlled Substances Act) and alcohol is prohibited on Sustaining Grace Consulting property or during a Sustaining Grace Consulting activity, and is sufficient cause for disciplinary action towards the contractor up to and including the termination of my contract.

Please initial

I understand that should I be contracted by Sustaining Grace Consulting, that my contract is considered "at-will". The term "at-will" means that either party may end the relation at any time, regardless of whether notice is submitted. That there is also no promise or guarantee of a contract or that my contract will continue for any specified period of time. Nothing in this Application creates a contract or relationship between I and Sustaining Grace Consulting.

Please initial

I understand that any verbal communication between I and Sustaining Grace Consulting regarding my contract is not binding upon Sustaining Grace Consulting. That the specific terms and conditions for my contract must be confirmed in writing by an authorized representative from Sustaining Grace Consulting.

Please initial

I understand that Sustaining Grace Consulting can contact any of my previous employers, past educational institutions, governmental databases, and provided reference to verify the truth of any information I have provided on my Application or in any other supplemental documents. I also authorize these organizations and individuals to provide the information requested by Sustaining Grace Consulting.

Please initial

You acknowledge and agree that your electronic signature is being used for the purpose of submitting your Contractor Application. You understand that by typing your name and clicking on the "I Acknowledge" checkbox that it will represent your electronic signature. By clicking on the "I Acknowledge" checkbox, you recognize that signing and submitting this document with your electronic signature is legally equivalent to placing your handwritten signature on the document. You also understand and agree that by submitting your electronic signature alongside this document, that you certify all of the information provided in this document is truthful.

Please initial

Name of Applicant

I acknowledge

Today's Date

YYYY

Is there any other information that would like to inform us about?