Employment Application — Three Oaks Behavioral Health & Wellness

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Our Why; Mission & Core Values

What's in a name?

Operations Team

Chapel Hill - Cloister

Chapel Hill - Southern Village

Downtown Raleigh

Midtown - Raleigh

Internship Program

Psychological Evaluations

Emergency/Crisis Contacts

Video Resources

English

Our Why; Mission & Core Values

What's in a name?

Operations Team

Chapel Hill - Cloister

Chapel Hill - Southern Village

Downtown Raleigh

Midtown - Raleigh

Internship Program

Psychological Evaluations

Emergency/Crisis Contacts

Video Resources

English

Folder: Meet the Team

Folder: Programs

Folder: Services

Folder: Resources

Our Why; Mission & Core Values

What's in a name?

Operations Team

Chapel Hill - Cloister

Chapel Hill - Southern Village

Downtown Raleigh

Midtown - Raleigh

Internship Program

Psychological Evaluations

Emergency/Crisis Contacts

Video Resources

Clinical Employment Application

Name *

First Name

Last Name

Preferred Name/Nickname

Pronouns

Email *

Phone Number *

(###)

###

####

How did you learn about Three Oaks? *

If a specific person introduced you to Three Oaks, please indicate their name.

Are you aware of any dual relationship(s) between yourself, current employee(s), and/or client(s) of Three Oaks? If so, please explain.

Please describe, and omit any information that would jeopardize a client's confidentiality.

Position Sought *

Desired Start Date *

Desired Pay

$

Preferred Office Location(s) *

Please check all that apply.

Apex (56 Hunter Street)

Chapel Hill (Southern Village, Market Street)

Chapel Hill (Cloiser Court)

Downtown Raleigh (Washington Street)

East Raleigh (Dresser Court)

Garner (US 70 Hwy W)

Midtown Raleigh (Benson Drive)

North Durham (Guess Road)

North Raleigh (Professional Court)

Pittsboro (Hillsboro Street)

South Durham (Lyckan Parkway)

West Raleigh (Creedmoor Road)

Virtual (Telehealth Only)

EDUCATION

College (Graduate)

Please include the name of your graduate program/university, degree, and year graduated (or anticipated graduation date).

College (Undergraduate)

Please include the name of your undergrad program/university, degree, and year graduated.

High School

Please include the name & location of your high school and year graduated.

PROFESSIONAL EXPERIENCE

Are you currently employed? If so, where? *

Licensure Status:

Awaiting license (recent graduate)

Provisionally licensed

Fully licensed

Date of Licensure:

If PL, estimated month/year of achieving full licensure. If FL, month/year full licensure was reached.

Licensure Number(s), Issue Date(s), Expiration Date(s), NPI, CAQH (if available)

Specialties, Preferred Modalities, Desired Client Population (age range, presenting symptoms, etc.)

Are you currently credentialed with any of the following insurance companies? *

BCBS

Aetna

Evernorth (formerly Cigna)

I am not yet credentialed.

Professional References:

Please list name, email & phone number.

Professional Profile

If you'd like to share your LinkedIn page, please paste the URL here.

http://

Is there anything else you'd like to share?

Thank you for your submission. We look forward to getting in touch with you soon!

Three Oaks Behavioral Health & Wellness

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Mailing Address

1011 Dresser Court
Raleigh, NC 27609

Contact Us

General Mailbox
(919) 514-3566

Fax
Medical Records Requests: (919) 516-0057
Client Referrals: (919) 386-2098

*No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All OPT-IN requests include text messaging originator opt-in data and consent; this information will not be shared with third parties.