Employment Application

Chrissandra M. Andra, LCSW, PLLC

Phone: 815-600-3107 ~ info@queerbehaviors.com ~ Fax: 866-500-5380

Name*

(Please note that this information will be publicly available on the practice’s website if hired)

Personal Phone

Work Phone*

(Please note that this information will be publicly available on the practice’s website if hired)

Email*

Location of Primary Residence*

Professional Status*

BA Candidate / BSW Candidate / Undergraduate Student

MSW Candidate / Graduate Student

LMSW

LCSW

I am interested in the role(s) of:*

DBT Consultation Team Lead

Anti-Oppressive Practice Team Lead

Psychotherapist

I am interested in being:*

An intern

An independent contractor (i.e., 1099)

An employee (i.e., W-2)

I would like more information about teams at the practice*

DBT Consultation Team

Anti-Oppressive Practice Team

Research Team

Emergency Contact (include name, number, and relationship)*

Personal & Professional Goals
Please describe how this position will fit in with your current life and schedule, and support your goals.
Please limit to 3 paragraphs or less.*

Statement of Interest
Please describe how you would be a good fit for working with me and the populations my practice serves (i.e., gender and sexual minorities).
Please limit to 3 paragraphs or less.*

Availability
Please list your availability to see clients and attend meetings, noting any preferred days and times. Please also indicate if you are looking to provide in-person, virtual, or hybrid services.*

License Type(s)*

(Please note that this information will be publicly available on the practice’s website if hired)

State(s) & License Number(s)*

Date(s) of Issue*

Date(s) of Expiration*

National Provider Identifier (NPI)*

(CAQH)*

National Association of Social Workers (NASW) New York State Chapter: https://naswnys.org/

*NPI: https://nppes.cms.hhs.gov/#/
**CAQH: https://proview.caqh.org/Login/Index?ReturnUrl=%2f

Clinical Experience 1

Site*

Title*

Job Description*

Start Date*

End Date*

Supervisor & Contact Information of Supervisor*

Population Served*

Modalities Used*

Clinical Experience 2

Site

Title

Job Description

Start Date

End Date

Supervisor & Contact Information of Supervisor

Population Served

Modalities Used

Clinical Experience 3

Site

Title

Job Description

Start Date

End Date

Supervisor & Contact Information of Supervisor

Population Served

Modalities Used

Additional Clinical Experience

Education

Undergraduate Education

Institution

City, State, Country

Degree

Major

Year Awarded

Graduate Education 1

Institution*

(Please note that this information will be publicly available if hired)

City, State, Country*

Degree*

(Please note that this information will be publicly available on the practice’s website if hired)

Program Name*

(Please note that this information will be publicly available if hired)

Year Awarded*

Graduate Education 2

Institution

(Please note that this information will be publicly available if hired)

City, State, Country

Degree

(Please note that this information will be publicly available on the practice’s website if hired)

Program Name

(Please note that this information will be publicly available if hired)

Year Awarded

Additional Graduate Education

Modalities

Modality 1

Name of Modality (e.g., DBT)*

(Please note that this information will be publicly available on the practice’s website if hired)

Number of years Practicing Modality*

Training/Course 1 Name, Dates, & Trainer(s)/Instructor(s):*

Training/Course 2 Name, Dates, & Trainer(s)/Instructor(s):

Training/Course 3 Name, Dates, & Trainer(s)/Instructor(s):

Training/Course 4 Name, Dates, & Trainer(s)/Instructor(s):

Modality 2

Name of Modality

(Please note that this information will be publicly available on the practice’s website if hired)

Number of years Practicing Modality

Training/Course 1 Name, Dates, & Trainer(s)/Instructor(s):

Training/Course 2 Name, Dates, & Trainer(s)/Instructor(s):

Training/Course 3 Name, Dates, & Trainer(s)/Instructor(s):

Training/Course 4 Name, Dates, & Trainer(s)/Instructor(s):

Modality 3

Name of Modality

(Please note that this information will be publicly available on the practice’s website if hired)

Number of years Practicing Modality

Training/Course 1 Name, Dates, & Trainer(s)/Instructor(s):

Training/Course 2 Name, Dates, & Trainer(s)/Instructor(s):

Training/Course 3 Name, Dates, & Trainer(s)/Instructor(s):

Training/Course 4 Name, Dates, & Trainer(s)/Instructor(s):

Additional Modality

Publications (include most recent or cited)

Publication 1

Publication 2

Publication 3

Publication 4

Publication 5

Additional Publications

Would you like to have your publications included on the practice website (if hired)?

Yes

Conference Presentations &/or Seminars

Conference/Seminar 1

Conference/Seminar 2

Conference/Seminar 3

Conference/Seminar 4

Conference/Seminar 5

Additional Conference(s)/Seminar(s)

Would you like to have your conference presentations &/or seminars included on the practice website?

Yes

Please include any additional information you’d like us to consider here.