Changing Minds Psychiatry is a collaboration of passionate people dedicated to creating the finest patient experience as we enable people to take back their lives from depression, anxiety, and other life-impacting conditions. We are growing rapidly, and with continued growth anticipated for the foreseeable future, there’s never been a better time to join Changing Minds Psychiatry and grow your career alongside our company growth.

Online Application to Contract

Once the application starts you wont be able to stop, save and come back to complete it.

PERSONAL INFORMATION

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Business Name & License Number

How did you learn of this position? (If company employee list employee’s name.)

EMPLOYMENT DESIRED

Position Desired

Date available to start

YYYY

Work Schedule Desired

Hours Available

Example: Monday 9am - 5pm, Tuesday 10am - 5:30pm, etc

Salary Desired

EDUCATION

1a. Education - College

Institution Name/City

1b. Education - College

Major and Degree

2a. Education - Graduate School

Institution Name/City

2b. Education - Graduate School

Major and Degree

List any job-related special training or certifications you hold.

LICENSURE

Professional License #

Type of License

State you are licensed in

Do you require supervisor or collaboration to fully practice? If so, who is that person?

What EHRS have you used?

EHRS - Electronic Health Record System

Foreign Languages Spoken

What insurance companies are you currently credentialed with? If any? Medicaid, Medicare?

Any Disciplinary past or present against your prescribing authority? (Med Managers only)

Our core values are Passion, People, Progress, and Community. How would you display these values in your practice?

WORK HISTORY

(Please list all employers and periods of unemployment. Complete even if you attach a resume)

Employer #1

Are you currently employed or contracting with any company in the same business as Changing Minds Psychiatry? If so, please provide the name of company and hours or days you are contracted to work with them.

Dates (To/From)

Position/Title

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Supervisor Name:

Supervisor Phone Number

(###)

###

####

Salary

Bonus

Duties:

Reason for Leaving

Employer #2

Dates (To/From)

Position/Title

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Supervisor Phone Number:

Supervisor Phone Number

(###)

###

####

Salary

Bonus

Duties:

Reason for Leaving

Employer #3

Dates (To/From)

Position/Title

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Supervisor Name:

Supervisor Phone Number

(###)

###

####

Salary

Bonus

Duties:

Reason for Leaving

REFERENCES

(List three professional references that can attest to your clinical practice)

Name #1

First Name

Last Name

Relationship

Number of Years Known

Phone Number

Name #2

First Name

Last Name

Relationship

Number of Years Known

Phone Number

Name #3

First Name

Last Name

Relationship

Number of Years Known

Phone Number

PLEASE READ CAREFULLY, INITIAL EACH PARAGRAPH AND SIGN BELOW.

If I am a contract, I will, prior to commitment of the contract, be required to produce sufficient documentation of my identity and right to work in the United States and to attest under penalty of perjury that the documents I have produced are genuine and relate to me pursuant to the Immigration Reform and Control Act of 1986.

Initials

I understand that any false statement, misrepresentation, or omission of facts on this application or on any supporting documents, regardless of when they are discovered, will result in my immediate dismissal or removal of my application from consideration of employment. I certify that the information I have provided in this application is true and complete.

Initials

I understand that I will be required to possess a current valid license to practice in the state of Nevada.

Initials

I understand and agree that Changing Minds is a drug free workplace company, and I will be required to comply with that.

Initials

I authorize investigation of all statements contained in this application and any supporting documents. I authorize Changing Minds, LLC to secure information about my experience from former employers, educational institutions, government agencies, or any references I have provided, and for those parties to provide information concerning my experience and I hereby release all parties from any liability arising in relation to such investigation.

Initials

I understand that I am an contracted with Changing Minds, I must notify them if I am to contract with any other company that is within the same business type of Changing Minds at anytime during the contract with Changing Minds.

Initials

I have read, understand, and agree to the following, and that to the best of my knowledge and belief, the information on this application is true, correct, and complete.

Typing Your Name As Signature/Acknowledgement