Mid-Ohio Psychological Services

Application for: Clinical Supervisor Position

Mid-Ohio Psychological Services, Inc (MOPS) is an equal opportunity employer and considers applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.

Step 1

Basic Information
Step 2

Resume Details
Step 3

MOPS Agreement Form

Basic Information

* First Name	Middle Name .	* Last Name
Address:
City:	State:	Zip:
Social Security Number:	* Contact Phone:	* Contact Email:

Applicant Information

Salary Desired:
First Date Available:
Hours Available:	Full-Time Part-Time
How were you referred to MOPS?:
Are you currently employed?:	Yes No If yes, where are you currently employed?: May we contact your current employer:
Are you on a lay-off and subject to recall?:	Yes No
Can you travel if the job requires it?:	Yes No
Have you ever been convicted of/pled guilty or no contest to a crime including traffic violations? This agency conducts background checks under the reason code of Medicaid Provider. As a Medicaid Provider, the agency is required to exclude applicants with convictions listed on the Ohio Disqualifying Offenses List and in some cases, even sealed records will appear on a background check when it is conducted. If you have any questions, please reach out to HR at hr@mopsohio.com.	Yes No If yes, for each conviction, provide the date and place of conviction and the type of crime, below: Characters Remaining: 400/400 A conviction will not necessarily bar you from employment. If you have concerns regarding a conviction that may appear on your background check, please address it with HR if an offer of employment is made, prior to attending orientation and conducting the required background check.
Are you a U.S. citizen?:	Yes No If No to the above, are you able to provide documents required to establish your eligibility to work in the U.S.?: Yes No
Have you lived outside Ohio in past 5 years?:	Yes No
Any known scheduling restrictions or conflicts?:	Characters Remaining: 400/400

Military Background Information

Are you currently or formerly part of the Military?

Yes No

Branch of Service:		From:	To:
Rank/Type of Service:
Special Training/Experience:	Characters Remaining: 400/400

Education Information

High School or last grade completed:

School Name:
Address:
Course of Study:			Years Completed:
Degree/Diploma:

College or Technical School:

School Name:
Address:
Course of Study:			Years Completed:
Degree/Diploma:

Other Schooling or Training:

School Name:
Address:
Course of Study:			Years Completed:
Degree/Diploma:

Employment Information

Present, or most recent Employment History:

Employer:			Phone:
Address:		City, State:
Title:		Supervisor:
Employed From:	To:	Last recorded salary:
Brief reason for Leaving:
Job duties, skills, and or qualifications:	Characters Remaining: 400/400

Additional Employment History:

Employer:			Phone:
Address:		City, State:
Title:		Supervisor:
Employed From:	To:	Last recorded salary:
Brief reason for Leaving:
Job duties, skills, and or qualifications:	Characters Remaining: 400/400

Additional Employment History:

Employer:			Phone:
Address:		City, State:
Title:		Supervisor:
Employed From:	To:	Last recorded salary:
Brief reason for Leaving:
Job duties, skills, and or qualifications:	Characters Remaining: 400/400

Master's Intern Section

High School or last grade completed:

Name of current College/University:
Type of Practicum/Internship Seeking:
Seeking (Please Choose One):
Desired start date for Practicum/Internship:
Total Number of Hours needed at site: Practicum:
Total number of hours needed at site: Internship:
What percentage of your hours needs to be direct client contact hours:
Total number of hours needed at site: Internship:
Does your program require group therapy experience? If so, how many hours?:	Characters Remaining: 400/400
Are there particular areas of experience that you are seeking in a practicum/internship? (If so, please list):	Characters Remaining: 400/400
Do you have any special supervision requirements as part of your program? (If so, please list).:	Characters Remaining: 400/400
What level of interest do you have in remaining at MOPS after your internship?:	Characters Remaining: 400/400
Do you have any scheduling restrictions?:	Characters Remaining: 400/400
Other Comments:	Characters Remaining: 400/400

Locations I am interested in for Master's Internship:

Work Related References

	Name	Occupation	Years Known	Phone Number
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2.
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List professional, trade, business or civic activities and offices held. (You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, handicap, or other protected status):

Characters Remaining: 400/400

Upload Resume

*A Resume may also be emailed directly to Careers@MOPSOhio.com if you do not have access to it right now

Sign MOPS Applicant Agreement

*Please download the Applicant Agreement form, review and sign, and upload here. You may also drop off this signed form in person, directly email to Careers@mopsohio.com, or fax in to (740)-687-6677 .
Sign Applicant Agreement Form

Submitting Application...

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