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First Name*

Last Name*

Email*

Phone*

Are you a licensed Social Worker?

Yes

No

Do you have an active Clinical Social Worker license in California state?

Yes

No

Do you have a Marriage & Family Therapy license issued by California state?

Yes

No

Do you have a Professional Clinic Counselor license issued by California state?

Yes

No

What is your license number?*

What is your license Expiration Date?*

Do you have BLS certification? *

No

Yes

List any other certification you have:*

Do you have the COVID Vaccination?*

No - Requesting Exemption

Yes - Vaccinated

Yes - Vaccinated with Booster

Typically for strike assignments: 5x12/hr shifts (60/hrs week) Are you ok with this?*

No

Yes

Can you work a Day shift?*

No

Yes

Can you work a Mid shift?*

No

Yes

Can you work a Night shift?*

No

Yes

What is your Primary Shift preference?*

Day

Mid

Night

100% Flexible

How many years experience do you have as a licensed Social Worker?*

Have you done Social Work in the past year?*

No

Yes

At what facility have you worked as a licensed Social Worker most recently?*

What charting/EMR systems are you familiar with?*

Are you experienced in Nephrology?*

No

Yes

What settings are you experienced to work (hospital, clinic, nursing home, etc)?

How much experience do you have coordinating care for hospice patients?*

Describe any experience you may have working in or supervising a mental health call center:*

How much experience do you have with home social visits?*

Are you comfortable driving to home visits on your own?*

No

Yes

Are you comfortable using ride-share services (Uber, Lyft) for transportation to and from visits?*

No

Yes

Please supply an Emergency Contact name and phone number:*

Potential California Strike

Submit Request