HR Applications



Changing Lives at Home Inc, Application

* required fields

Applicant Information

* First Name
MI
* Last Name
Suffix
* SSN
* DOB
* Race
* Cell Phone Number ext.
* Cell Phone Carrier
Address
Street 1
Street 2
City
Postal Code
State/Region
Country
* Position Applying For
* Program Applying For
* Email
* Phone ext.
* Date Available
* Hours Available
* Are you at least 18 years of age?
* Are you able to perform the essential job functions of the position you are applying with or without reasonable accommodations?
* Have you ever been convicted of a crime, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by court? A yes response does not automatically disqualify your application. If yes, please explain
* Do you type?
* Computer Skills
Education
High School Info
High School Name
HS Address
HS Major Studies
Degree, Diploma, License, or Certificate
College 1 Info
College/University Name
Address of College/University
Major Studies: College/Univeristy
Degree, Diploma, License or Certificate: College/Univeristy
College 2 Info
College/University Name 2
Address of College/University 2
Major Studies: College/Univeristy 2
Degree, Diploma, License or Certificate: College/University
Grad School Info
Graduate School
Graduate School Address
Major Studies
Degree, Diploma, License, or Certificate: Graduate
Vocation/Business School Info
Vocation/Business/Other Name
Address of Vocation School
VB Major Studies
VB -Degree, Diploma, License, or Certificate
Skills
Other Special Knowledge, Skills or Qualifications
Military Service
Employment History
Employer 1
* (1) Is this your current employer?
* (1) May we contact this employer for references?
* (1) Employer Name:
* (1) Employer Address:
* (1) Employed From:
* (1) Employed To:
* (1) Job Title:
* (1) Salary/Pay Amount:
* (1) Supervisor Name:
* (1) Supervisor Phone: ext.
* (1) Job Duties & Responsibilities
* (1) Reason for Leaving
Add Another Employment?
Employer 2

(2)May we contact this employer for references?
(2) Employer Name:
(2)Employer Address:
(2) Employed From:
(2) Employed To:
(2) Job Title:
(2) Salary/Pay Amount:
(2) Supervisor Name:
(2) Supervisor Phone: ext.
(2) Job Duties & Responsibilities:
(2) Reason for Leaving
(2)Add Another Employment? (It is recommended that you provide accurate and detailed history.)
Employer 3
(3)May we contact this employer for references?
(3) Employer Name:
(3)Employer Address:
(3) Employed From:
(3) Employed To:
(3) Job Title:
(3) Salary/Pay Amount:
(3) Supervisor Name:
(3) Supervisor Phone: ext.
(3) Job Duties & Responsibilities:
(3) Reason for Leaving:
(3)Add Another Employment? (It is recommended that you provide accurate and detailed history.)
Employer 4
(4) Employer Name:
(4)Employer Address:
(4) Employed From:
(4) Employed To:
(4) Job Title:
(4) Salary/Pay Amount:
(4) Supervisor Name:
(4) Supervisor Phone: ext.
(4) Job Duties & Responsibilities:
(4) Reason for Leaving:
Volunteer/Hobbies
Volunteer Activities
Hobbies /Interests (Optional)
References
* Reference #1 Email Address
* Reference #1 Name
* Reference #1 Phone Number ext.
* How many years have you known this person?
* Reference #2 Email Address
* Reference #2 Name
* Reference #2 Phone Number ext.
* How many years have you known this person? (2)
* Reference #3 Email Address
* Reference #3 Name
* Reference #3 Phone Number ext.
* How many years have you known this person? (3)
Certification and Writing Sample

Certification and Authorization
The above information is true and correct.

I authorize Changing Lives at Home to inquire into my education, past employment history, and references as needed to research my qualifications for this position.

If employed or contracted, I will be required to provide original documents which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986. The document(s) provided will be used for the completion of Form I-9.

I hereby acknowledge that I have read and agree to the above statements.

* Certification Signature

Reset Signature
PRP Writing Sample

Please read and complete the following writing sample to the best of your ability. It will be used to judge your competency to complete required client documentation and reports.

Scenario: You met with client, Jennifer Roe, at 2:00pm on Tuesday, December 22 2015. On arrival, you noticed that the client seemed to be down. Upon inquiring about client’s current state, Ms.Roe informs you that she had been very depressed over the past few days. Ms.Roe also states that she has not been taking her medication and attributes that to her change in mood.

Client’s current long term goals are:

Long term goal 1: Individual will learn how to improve symptom management by identifying triggers to negative coping skills (i.e. over eating, sleeping, isolation)

Long term goal 2: Individual will learn to manage medication by implementing routines and effective methods.

Long term goal 3: Individual will be educated on the benefits of proper diet and exercise through the use of the food pyramid and recommended.

* 1. Based on client’s long term goals, explain what you would do to assist the client during this visit? What activities/coping mechanisms would you suggest, if any? What suggestions would you give to the client to assist her with lessening the effects of her depression?
* 2. Now, write a note about your visit
* CLIENTS NAME:
* DATE OF VISIT:
* TIME OF VISIT:
* SESSION SUMMARY:
* FOLLOW-UP PLAN/PLAN FOR NEXT VISIT:
* REASON FOR VISIT
* Add Resume?
* E-Signature

Reset Signature
* E-Signature Date



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