Your Information

Phone Number

Email Address

Position Information

Program Applied For
Central PA (Harrisburg Area)Western PA (Pittsburgh Area)Eastern PA (Philadelphia Area)Southwest PA (Somerset Area)

Desired Independence Level of Individual
Highly Independent (1-6 hour care)Fairly Independent (6-12 hour care)Moderately Dependent (12-18 hour care)Fully Dependent (18-24 hour care)

Date Available To Start

Other Information

How Did You Hear About Focus Behavioral Health, Inc.? (i.e. friend, co-worker, walk-in, etc.)

Have You Ever Been Employed By Any Affiliate Or Division Of Focus Behavioral Health, Inc.?
YesNo

If Yes, Give Entity And Date(s)

Are You Authorized To Work In The United States?
YesNo

Personal Experience

Please describe some of your personal, educational, and/or work experiences that would display your ability to be a caregiver to an adult with a disability.

Background Clearance Information

Please write the full names, social security numbers, and date of births for every person residing in the household (despite age)

Driver's License Information

*A Valid Driver's License And Acceptable Driving Record Is Required

Driver's License State

Driver's License Number

Currently Valid?
YesNo

Professional Licenses And/Or Certifications

List Any Professional Licenses & License Number(s)

Has Your Professional License Ever Been Suspended Or Revoked?
YesNo

If Yes, Please Explain

List Any Certifications You Hold

References

Give Three References

Reference #1

Name

Phone

Occupation

Reference #2

Name

Phone

Occupation

Reference #3

Name

Phone

Occupation

Authorization And Release Of Information

I hereby give Focus Behavioral Health, Inc., and any of its affiliates and divisions, the right to thoroughly investigate my past employment, education, police record, activities, and I release from all liability all persons, companies, and corporations supplying such information. I indemnify Focus Behavioral Health, Inc. against any liability which might result from conducting such an investigation.

Initials

I understand that any false answers or statements or implications made by me in this application or other required documents shall be considered sufficient cause for denial of application or discharge.

Initials

Additionally, I understand that nothing contained this application or in the granting of an interview is intended to create a contract between Focus Behavioral Health, Inc. and myself for the providing of any benefit. No promises regarding application have been made to me and I understand that no such promise or guarantee is binding upon Focus Behavioral Health, Inc. unless made in writing by the President.

Initials

If any relationship is established, I understand that I have the right to terminate my application at any time for any reason or no reason at all, with or without prior notice, and that Focus Behavioral Health, Inc. retains the same right.

Initials

You consent and agree that your use of a key pad, mouse or other device to select an item, button, icon, checkbox, to enter text, or to perform a similar act/action, constitutes your signature, acceptance and agreement as if actually signed by you in writing. You further acknowledge and agree that the taking of any such actions by you is the only evidence needed of your intent to sign any such agreement, acknowledgment, consent, terms, disclosures or conditions. You also agree that no certification authority or other third party verification is necessary to the validity of your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or any resulting contract.

Initials

Signature (Please Type Name As It Would Appear On Your Signature)

Please leave this field empty.