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Please Complete This Form to Apply to Leek Therapy

First Name

Last Name

Email *

Phone *

Ok to text on this number?: *

Yes

No

Town where you currently reside:

Seeking Part-Time Employment (8 sessions per week minimum)?

Yes

No

Seeking Full-Time Employment (20 sessions per week minimum)?

Yes

No

Can you work evening and/or weekend hours, at least in the beginning to build your caseload?

Yes

No

License Type (in state of MA)?

LMHC

LADC

LICSW

LCSW

Pre-LMHC

Pre-LICSW.

Other

Other License Type (in state of MA)

Do you require supervision for licensure (provided in-house)?

Yes

No

How long do you see yourself staying in a group practice (minimum of 2 years preferred)?

Where would you like to perform your client sessions?

100% TeleHealth

100% In-Person

Hybrid Model

Number of years working in the mental health field?

Anything you would like to share with the Clinical Director before your first interview?

Please upload your resume here:

I Consent to Receive SMS Notifications, Alerts & Occasional Communication from Leek Therapy.

Insurance Accepted

Eligibility of Benefits Provided

Accepts Online Payments

Hassle Free Online Payments

Excellence

Integrity

Honesty and Transparency

Excellence

Offering Online

Telehealth Appointments

Insurance Accepted

Eligibility of Benefits Provided

Accepts Online Payments

Hassle Free Online Payments

Excellence

Integrity

Honesty and Transparency.

Excellence

Offering Online

Telehealth Appointments.

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COMPANY

CLIENT CARE

INSURANCE ACCEPTED

LEGAL

NOTICE OF PRIVACY PRACTICE

LICENSE AGREEMENT

NO SURPRISE ACT

You have the right to receive a Good Faith Estimate of what your services may cost

FIND US

COMPANY

CLIENT CARE

LEGAL

NOTICE OF PRIVACY PRACTICE

LICENSE AGREEMENT

NO SURPRISE ACTYou have the right to receive a Good Faith Estimate of what your services may cost

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