EmailMe Form - NYTPS Placement Questionnaire

Name *

First Last

E-mail Address: *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Cell Number *

### - ### - ####

Type of Provider
(Please choose at least one) *

Please specify if you are looking for work in Nassau, Suffolk or the 5 Boroughs. *

Nassau

Suffolk

Five Boroughs

Other - Please explain

Full Time

Part Time

Number of days/ hours available *

Please check off the appropriate box/boxes to let us know if you would like to be contacted on the following:

Cases *

Are you interested in face to face or remote therapy cases? *

Face to Face Cases

Remote Therapy Cases

Both

**If interested in Early Intervention cases you MUST hold a Department of Health (DOH) Clearance letter. Do you have a DOH Clearance letter? *

Yes

No

Evaluations *

Early Intervention

Preschool

School Age

Private Pay/Insurance

Are you bi-lingual?

Yes

No

If yes, what languages?

How did you find about NY Therapy

Colleague

Postcard

Please upload your resume here