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MHRS Provider Employment Application

Section I - Position & Agency Information

Agency/Name:

Position Applied For:

Department/Team:

Supervisor/Manager:

Employment Type:

Full-Time

Part-Time

Conntractor

Start Date (or ASAP):

Section II - Personal & Contact Details

Full Legal Name:

Preferred Name/Nickname:

Address:

Phone Number (Cell/Home):

Email:

DC Residency:

Yes

No

(If no, specify state):

License Type:

Section III - Licensure & Credentials

License #:

Issuing Jurisdiction:

Expiration Date:

Proof of Licensure:

Certifications (EBPs, CPR, First Aid, etc.):

Section IV - Education & Clinical Training

Highest Degree Earned:

Institution:

Graduation Date:

Other Relevant Education/Training:

Section V - Employment History (Last 5 Years)

Employer, Dates, Position Title, Key Responsibilities:

Resume/CV:

Role-specific Position Description Attached:

Section VI - Core Competencies & Clinical Skills

List Core Competencies & Clinical Skills with the following:

Psycho-social assessments:

Person-centered treatment planning:

EHR/documentation familiarity:

DBH/BHSD data submission & billing:

MHRS services delivered: Evidence-Based Practices facilitated:

Telehealth/Out-of-State service compliance:

Section VII - Background & Compliance

DC Criminal Background Clearance:

Yes

No

Date

Month

Day

Year

Child Protection Registry Clearance:

Yes

No

Date

Month

Day

Year

Drug Screening completed within 90 days:

Yes

No

Date

Month

Day

Year

Liability Insurance:

Yes

No

Proof of Liability Insurance:

Section VIII - Agreements & Attestations

I hereby attest that I meet all DC licensure and certification requirements, comply with Medicaid and MHRS billing/documentation standards, and agree to abide by Title 22-A DCMR regulations.

Signature

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Section IX - References

Full Name:

Relationship:

Email:

Phone:

Full Name:

Relationship:

Email:

Phone:

Full Name:

Relationship:

Email:

Phone:

Section X - Additional Attachments

Resume / CV:

Professional Licenses & Certifications:

Background & Screening Documents:

Continuing Education Certificates:

Our Community Support Services

Main: (888) 292-0890

Fax: (202) 559-2477

kgraham@ourcommunitysupport.org

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