Your contact information:
Full name:
Email address:
Mailing address:
Telephone number:
Best Time to Contact:
Best Method to Contact:
Position Applying For:
Your work history:  Email your resume to: brad@alightclinic.com; admin@alightclinic.com
Are you licensed in the State of Texas?	Yes No
Speciality area of interest:
On a scale of 1-10 (1 being "not at all" and 10 being "completely"), how comfortable are you working:
With children with special needs:
As the only therapist of your discipline in a setting:
As a member of a team:
With a mentor:
Do you have any pediatric experience?	Yes No
Long range plans (3-5 years):
Are you familiar with web-based EMR or Advanced MD?	Yes No
Have you worked with Medicaid?	Yes No
Are you familiar with units?	Yes No
If so, how many do you bill in an average week?
Background information:
Are you a citizen of the United States?	Yes No
If not, are you eligible to work in the United States?	Yes No
Are you bilingual?	Yes No
If so, what languages do you consider yourself fluent?
Are you able to work four 10 hour days?	Yes No
Are you able to work late hours?	Yes No
Are you currently employed?	Yes No
When are you available to start working?