Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
License Type and Number
*
If licensed, are your enrolled as a Medicare provider?
Yes
No, I have completed the Medicare Opt Out Affidavit
I don't know
If prelicensed, approximately how many hours of experience do you currently have?
Do you have malpractice insurance?
*
YES, it's current!
NO, and I don't plan to get it.
NO, and I will get it when I start seeing clients at IECC
Are you willing to provide a complete employment history and list of professional references if requested?
YES
NO
Are you willing to disclose where else you are working if you have another job concurrently with this one?
YES
NO
Do you have any experience working in a private practice setting?
YES
NO
If Yes, please explain.
Do you have any hesitation about working alone in the office?
YES
NO
If Yes, please explain or ask your questions.
We're happy to respond to your concerns and answer your questions. We want to make sure this is a good fit and that you'll feel comfortable working here. An anxious therapist will be less effective with their clients and more prone to burnout.
Will you be able to attend our weekly virtual team meeting on Thursdays from 1:00 - 2:00 pm?
YES
NO
Are you available to work consistent shifts every week, including some evening and/or weekend hours? Our clients come weekly. This isn't a position where you can work just one day a month.
YES
NO
Which office are you wanting to work out of?
Riverside
Murrieta
What days and times are you available to see clients?
What are your desired minimum and maximum hours worked in a week?
Why are you interested in working for Inland Empire Couples Counseling?
Describe your experience in working with electronic documentation. What do you love about it? What challenges have you faced?
Explain your preferred modality or approach with couples therapy. Why does this approach appeal to you or make sense to you and your clients? What successes have you had using that approach in couples work? And what are the weaknesses in this approach?
Which professional training are you interested in to further your couples therapy skills?
What unique client populations would you like to serve? (In other words, do you have a special place in your heart for a particular type of client or problem?)
What are your big dreams for your life's work? Forget for a moment how unrealistic they might seem and let yourself dream. What impact do you want to have on the world?
Describe how you manage confidentiality with a client couple. What unique legal or ethical considerations do you consider when working with a client couple? How would you explain this to your clients?
Your client couple comes to session and tells you about an argument they had. One of the partners tells you that the other blocked them from leaving the room and threw and broke a glass. What would you do?
One member of a couple you have been seeing shows up alone to the session. They said they got into a fight with their partner and the partner is refusing to come. This person didn't want to be charged the no-show fee, so they came alone. What would you do? Explain your reasoning.
You have been seeing a couple for several sessions now. They have been making some good progress. They surprise you with some new information and the session goes completely sideways. They aren't responding to your efforts to redirect them. You are completely taken off guard by this new information. How do you think you would handle this situation in the session? What steps would you take after the session? Please also include whether your answer is based on how you 'think' you would react in this situation or if your answer is coming from lived experience when something similar happened to you.
How do you define success for a client couple?
How do you nurture your clinical skills?
We all have therapeutic strengths and weaknesses. Is there a couples therapy skill or couple dynamic you find particularly challenging? Where do you see yourself getting stuck? What have you tried so far to address this clinical challenge?