Home
Services
The Team
The Space
Client Sign Up
Media
Staff Portal
Menu
302 E Manchester Blvd #203
Inglewood, CA, 90301
424-241-0164
Inglewood, CA
Your Custom Text Here
Home
Services
The Team
The Space
Client Sign Up
Media
Staff Portal
New Hire Info Grab Form
Please complete the form below:
Name
*
First Name
Last Name
Email
*
Personal phone #
*
(###)
###
####
Your Google voice #
*
You will need to create a Google voice # to communicate with clients. Please do so now and submit your Google voice #.
(###)
###
####
Date of First Registering with BBS
*
MM
DD
YYYY
BBS #
*
Have you had to register for a second BBS #?
*
Yes
No
NPI #:
*
Write "none" if not yet assigned. If you work for or worked for a DMH contracted clinic, you have an NPI number and will need to ask your current or previous employer.
Who is your ideal client and why?
*
Bio
*
Please provide info you think communicates who you are, why you chose healing as a profession, which kind of client you are looking for, and any other info you find helpful in capturing who and what you are.
What is your niche/speciality?
*
Ok to have more than one.
What is the max number of clients you'd like to see per week?
*
Please provide days and times you're available to see clients.
Name of Most Recent Supervisor
*
First Name
Last Name
Address of Most Recent Supervisor
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number of Most Recent Supervisor
*
(###)
###
####
What is one fun fact about you?
What's your favorite dish?
*
What is your favorite candy or snack?
*
Thank you!
