SLP Application | Mind & Motion

First name

Last name

Phone

Preferred Communication

Please provider the state you are licensed in and your license number. If you are not fully licensed, please type "in progress."

If you know your NPI, please provide it here.

Do you currently carry your own liability insurance?

Yes

Unsure

Please describe your preferred age, diagnosis, or population to work with.

Please describe your experience with EHR including which software if any.

Please describe your ideal availability such as part-time, full-time, specific days, or a sustainable caseload.

Where are you wanting to provide services?

Please upload your CV or resume with any relevant documentation.

CV or Resume

Copy of License

Liability Insurance

I understand this application is for contractor consideration and does not guarantee an interview, contract offer, or employment.