MINIMUM QUALIFICATIONS CHECKLIST



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In addition to answering the questions below regarding your qualifications, please submit a resume and cover letter with your Employment Application. Your cover letter should address why you are interested in working at Unity Care NW and describe your experience in a position of this type.

|QUALIFICATIONS |Yes |No |

|Are you certified as a Washington State Chemical Dependency Professional (CDP)? | | |

|Are you an independently Licensed Clinical Social Worker, Licensed Mental Health Counselor, Licensed Marriage & | | |

|Family Therapist, or Psychologist in Washington State (preferred, but not required)? Please indicate type of | | |

|license:       | | |

|If you are not currently independently licensed in WA State, what type of license do you have (for example, | | |

|Associate or Agency Affiliated) &/or are you eligible to be licensed in WA State (for example, if you are an | | |

|out-of-state candidate)? Please explain here:       | | |

|Are you eligible to provide clinical supervision to CDP trainees per Washington Administrative Code (WAC) | | |

|246-811-049. | | |

|Do you have any action on a state license or have any malpractice claims been made against you? If yes, please | | |

|explain:       | | |

|Do you have a current CPR/Basic Life Support (BLS) certification? If yes, please indicate expiration date:      | | |

|The Centers for Disease Control and Prevention strongly recommends the following vaccines for healthcare | | |

|workers:  Influenza, Measles, Mumps and Rubella (MMR), Varicella (Chickenpox), Tdap (Tetanus, Diphtheria, | | |

|Pertussis) and Tuberculosis screening. As a Unity Care NW employee, would you agree to follow these CDC | | |

|recommendations? | | |

I hereby certify that all statements made above are true and correct.

     

Signature Date

     

Print Name

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Chemical Dependency Professional

QUALIFICATIONS CHECKLIST

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