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Name
*
First
Last
Email
*
Phone
*
How many years of experience do you have?
*
What is your highest level of education? And where did you graduate?
*
Do you have a current South Carolina counseling license?
*
Yes
No
Which type of license do you have?
*
LPC (or LPC-S)
LISW-CP
LMFT
PsyD
Other
SC License Number (For verification purposes)
Are you currently credentialed with insurance companies? If so, which ones?
*
Describe your previous work experience and how it applies to this position?
*
Are you legally authorized to work in the United States?
*
Yes
No
Are you willing to undergo a background check?
*
Yes
No
Please list 3 professional references with contact information.
Please provide 3 dates / times you are available for an interview
Additional Details
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