Join our team of passionate professionals at The Next Step Therapeutic Services LLC as we strive to make a positive impact on mental health. We seek dedicated individuals, eager to learn, innovate, and contribute to the field of therapy. Together, we’ll foster growth, support well-being, and change lives for the better.

50 W Queens Way Suite 101
Hampton, Va. 23669
Office: (757) 819-6958
Fax: (757) 900-9853

Personal

Today’s Date

Last Name

First

Middle

Date of Birth

Street Address

Home Phone

City, State, Zip Code

Business Phone

Email Address

S.S #

Emergency contact (person not living with you)

Have you ever applied for employment with this Agency?

Yes

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

Yes

How did you learn of our organization?

Newspaper AD

Emergency Employee

Other

Are you willing to work:

Evenings

Weekends

Position applying for:

LVN

Therapist (Specify)

Other

Education

School Name/School Location

Course of Study

Years Attended

Certificate/Degree/Diploma

School Name/School Location

Course of Study

Years Attended

Certificate/Degree/Diploma

School Name/School Location

Course of Study

Years Attended

Certificate/Degree/Diploma

School Name/School Location

Course of Study

Years Attended

Certificate/Degree/Diploma

Employment

List the last five years employment history, starting with the most recent employer.

1. Company Name:

Telephone:

Address

Street Address City State / Province / Region ZIP / Postal Code

Dates of Employment:

From - To

Starting Pay

Job Title and Describe your work:

Reason for leaving :

2. Company Name:

Telephone:

Address

Street Address City State / Province / Region ZIP / Postal Code

Dates of Employment:

From - To

Starting Pay

Job Title and Describe your work:

Reason for leaving :

3. Company Name:

Telephone:

Address

Street Address City State / Province / Region ZIP / Postal Code

Dates of Employment:

From - To

Starting Pay

Job Title and Describe your work:

Reason for leaving :

APPLICATION FOR EMPLOYMENT

Was your last name different from your present name during the above listed jobs?

Yes

If yes, what was your name?

Do you have reliable transportation?

Yes

PROFESSIONAL REFERENCES

Persons who can furnish information about job performance

1. Name:

Telephone:

Fax:

Address:

2. Name:

Telephone

Fax

Address

3. Name:

Telephone

Fax

General

Have you ever been convicted of a crime in the past 5 years, barring employment in a community support agency?

Yes

Have you ever been convicted of a felony?

Yes

Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:

Are you capable of performing the job set forth in the job description?

Yes

If you answered No, which job requirement are you unable to meet?

APPLICATION FOR EMPLOYMENT

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL

I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

Date

Signature

APPLICANT REFERENCE CHECK (1)

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.

To be filled out by applicant:

Applicant Name:

Date of Application:

Previous Employer:

Contact Person:

Address:

Phone

Fax

I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.

Applicant’s Signature:

Date

To be completed by previous employer:

Date of employment: From-To

Position Held

Would you rehire this individual?

Yes

Responsibilities:

Reason for Leaving:

Rate of Pay: (weekly/biweekly/salary):

Additional comments (training/skills)

Signature

Position/Title

Date

Office Use:

APPLICANT REFERENCE CHECK (2)

To be filled out by applicant:

Applicant Name:

Date of Application:

Previous Employer:

Contact Person:

Address:

Phone

Fax

Applicant’s Signature:

Date

To be completed by previous employer:

Date of employment: From-To

Position Held

Would you rehire this individual?

Yes

Responsibilities:

Reason for Leaving:

Rate of Pay: (weekly/biweekly/salary):

Additional comments (training/skills)

Signature

Position/Title

Date

Office Use:

Employee Emergency Contact Information

Employee Name:

Current Address:

Home Phone:

Cell Phone:

Next of kin:

Phone

Relationship:

Address

*In case of emergency, please contact:

Name:

Phone:

Relationship:

Address:

*Please notify this Agency immediately if any of the emergency contact information changes.

Declaration of Under Penalty of Perjury

understand that any falsification or any misrepresentation or omission of facts shall be sufficient cause for disqualification of this application or termination of employment. Furthermore, it is understood that this application and records become the property of The Next Step Therapeutic Services, LLC, which reserves the right to accept or reject it. A criminal history on all applicants considered for hire by The Next Step Therapeutic Services, LLC shall be requested through The Department of Behavioral Health and Department of Social Service Central Registry as a pre-employment prerequisite. I certify under penalty of perjury under the laws of the State of Virginia and the United States of America that the foregoing is true and correct. Further, I hereby authorize The Next Step Therapeutic Services to make any investigation of my personal or employment history and authorize any former employer, person, firm, corporation, or government agency or the Virginia State Patrol or any Federal law enforcement agency to give The Next Step Therapeutic Services any information they may have regarding me. I further authorize The Next Step Therapeutic Services to disclose any information they may have regarding me if a different potential future employer of me requests such information. In consideration of The Next Step Therapeutic Services review of this application, I release The Next Step Therapeutic Services, LLC and all providers of information from any liability as a result of furnishing and receiving any of the above information. I also understand and agree that my employment is conditional until The Next Step Therapeutic Services performs and completes a background record check or while The Next Step Therapeutic Services waits while the hiring staff are making a final hiring decision as to whether or not I will be employed by The Next Step Therapeutic Services, LLC. I understand that my employment is conditioned on the completion of both of the above acts and until such time as they are completed, my employment shall only be as a prospective employee and will not in any way bind or require The Next Step Therapeutic Services, LLC to start or to continue my employment.

"I declare or certify, verify, or state under penalty of perjury that the foregoing is true and correct.

Executed on

Date

Signature

Print:

HR Manager

Date
MM slash DD slash YYYY

Signature

Print

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50 W Queens Way Suite 101

Careers

50 W Queens Way Suite 101
Hampton, Va. 23669
Office: (757) 819-6958
Fax: (757) 900-9853

Personal

Education

Employment

PROFESSIONAL REFERENCES

General

APPLICATION FOR EMPLOYMENT

APPLICANT REFERENCE CHECK (1)

APPLICANT REFERENCE CHECK (2)

Employee Emergency Contact Information

Declaration of Under Penalty of Perjury

Cell:

Cell:

Email Us

50 W Queens Way Suite 101

Quick Links

Our Services

Contact Us

Copyright © 2024 · The Next Step Therapeutic Services LLC · Website Design by SpringHive

Contact Us

Email Us

50 W Queens Way Suite 101

Careers

50 W Queens Way Suite 101 Hampton, Va. 23669 Office: (757) 819-6958 Fax: (757) 900-9853

Personal

Education

Employment

PROFESSIONAL REFERENCES

General

APPLICATION FOR EMPLOYMENT

APPLICANT REFERENCE CHECK (1)

APPLICANT REFERENCE CHECK (2)

Employee Emergency Contact Information

Declaration of Under Penalty of Perjury

Cell:

Cell:

Email Us

50 W Queens Way Suite 101

Quick Links

Our Services

Contact Us

Copyright © 2024 · The Next Step Therapeutic Services LLC · Website Design by SpringHive

50 W Queens Way Suite 101
Hampton, Va. 23669
Office: (757) 819-6958
Fax: (757) 900-9853