Independent Psychiatrist / Psychiatric Nurse Practitioner Careers Form

Full Name *

First Name

Last Name

Phone Number *

(###)

###

####

Preferred Contact Method

Email

Phone

Either

Are you currently under supervision for licensure hours?

Yes

No

Are you looking for clinical supervision?

Yes

No

Do you have experience with Employee Assistance Programs (EAP)?

Yes

No

Are you board-certified?

Yes

No

Do you have a DEA number to prescribe medication?

Yes

No

Do you prefer Telehealth, In-Person, or a mix of both?

Telehealth

In-person

Both

Are you open to working with adults, children, or both?

Adults

Children

Both