Apply for Mental Health Associate II - Adult Program

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Summary
Title:Mental Health Associate II - Adult Program
ID:87940
Location:Coos Bay, OR
Department:Client Services
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Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Attachments
Cover Letter:
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Application for Employment (2)
PERSONAL INFORMATION
Yes   No
Yes   No
Yes   No
Yes   No
EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

Yes   No

School 2

Yes   No

School 3

Yes   No

School 4

Yes   No

School 5

Yes   No
EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment

Employer 1

Yes   No

Employer 2

Yes   No

Employer 3

Yes   No

Employer 4

Yes   No

Employer 5

Yes   No
REFERENCES

Please provide three references (not relatives).

Reference 1

Reference 2

Reference 3
AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

National Provider Identifier (NPI)
The NPI is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Standard. An NPI is a unique identification number for covered health care providers, created to help send health information electronically more quickly and effectively.
If you have an NPI number, please enter here.
Family Members
Do you have any relative(s) currently working for the County?
Yes
No
If yes, please state name(s) and state relationship.
Qualified Mental Health Associate
Are you a qualified Mental Health Associate?
Yes
No
Bachelors degree in health/behavioral health
Do you have a Bachelors Degree in health/behavioral health or a combination of at least 3 years' of relevant work experience, training or education in mental health?
Yes
No
Driving Record
* Do you have a valid Oregon Driver's License?
Yes
No
A valid Driver's License is required for this position with safe driving record.  Selected candidate may be asked to undergo a DMV check.
AA Referal Source
Please select how you found out about this position opening.
Indeed
HR County website
Existing Employee
Relative
Government Employment Agency
Other
Veterans Preference NEW
Under Oregon law, veterans who meet minimum qualifications for a position may be eligible for employment preference. If you think you may qualify, please read the following checklist carefully. Check the box for each item that is appropriate. If you need further explanation or have special circumstances, please call Coos County (541) 396-7580.
Are you a Qualified Veteran?  Veterans who meet the minimum qualifications for a position open for recruitment may be eligible for preference.
Yes
No
If yes, please complete the information below.  If not, or you are not claiming Veterans Status, please skip to the last question, then sign.
Veteran Status. You may claim veterans' preference if you check at least one of the boxes below and provide proof of eligibility by submitting a copy of your DD-214 or 215.

"Active duty" does not include attendance at a school under military orders, except schooling incident to an
active enlistment or a regular tour of duty, or normal military training as a reserve officer or member of an
organized reserve or a National Guard unit.
I served on active duty with the Armed Forces of the United States for a period of more than 90 consecutive days beginning on or before January 31, 1955, and was discharged or released under honorable conditions; or
I served on active duty with the Armed Forces of the United States for a period of more than 178 consecutive days beginning after January 31, 1955, and was discharged or released from active duty under honorable conditions; or
I served on active duty with the Armed Forces of the United States for 178 days or less and was discharged or released from active duty under honorable conditions because of a service-connected disability; or
I served on active duty with the Armed Forces of the United States for 178 days or less and was discharged or released from active duty under honorable conditions and have a disability rating from the United States Department of Veterans Affairs; or
I served on active duty with the Armed Forces of the United States for at least one day in a combat zone and was discharged or released from active duty under honorable conditions; or
I received a combat or campaign ribbon or an expeditionary medal for service in the Armed Forces of the United States and was discharged or released from active duty under honorable conditions; or
I am receiving a no service-connected pension from the United States Department of Veterans Affairs.
QUALIFIED DISABLED VETERAN QUESTIONS: You may claim additional employment preference if you can check at least one box in the section below and provide proof of eligibility by submitting both of the following documents:

1. A copy of your DD-214 or 215, Certificate of Release or Discharge, Copy 4, and
2. A public employment preference letter from the United States Department of Veterans Affairs.
To order the letter, call 1-800-827-1000 and request a public employment preference letter.
I am entitled to disability compensation under laws administered by the United States Department of Veterans Affairs; or
I was discharged or released from active duty for a disability incurred or aggravated in the line of duty; or
I was awarded the Purple Heart for wounds received in combat.
* I hereby Claim Veterans preference and certify that the above information is true and correct.  I understand that any false statements may be cause for my disqualification or dismissal, regardless of when discovered.  I will enclose a copy of my DD214/ 215 in all cases.  If you are claiming disabled Veteran preference you must also submit the public employment preference letter from the United States Dept of Veteran's Affairs.  Applications without qualifying documents will not be given preference.
Yes
No
I do not qualify for Veterans Preference status, or I am not claiming Veterans status.
Yes
No
* Signature (type name).  REQUIRED
* Date
Add your DD214/215 here.
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female Male I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Individual with a Disability
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
I Choose Not to Respond

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
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