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• Resume/CV ✱
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• Full name✱
• Pronouns
  He/him
  She/her
  They/them
  Xe/xem
  Ze/hir
  Ey/em
  Hir/hir
  Fae/faer
  Hu/hu

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  • Use name only

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  • Custom

  Let the employer know what pronouns you use so that they can address you correctly.

• Email✱
• Phone ✱
• Current location ✱
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• Current company

Preferred Name

• What is your preferred name?

PMHNP Application Questions

• How many years of experience do you have as a PMHNP✱

  Select...New Grad0-112345678910111213141516171819202122232425262728293030+
• What state do you reside?✱

  Select...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
• Please carefully review the office location in the job posting. Do you have an active PMHNP license in the state of this office?✱

  Select...YesNo
• This role is hybrid working several day per week onsite. Only local candidates will be considered. Do you live within a commutable distance from the city in the job title?✱

  Select...YesNo
• (CA PMHNP ONLY) Does your license include the status as a 103 NP in California? To be classified you must complete a 103 application with the state of CA and have 4600 hours of supervision and 3 years of experience verified. Please only select yes if you have had this application completed and your license updated to reflect the 103 status?✱

  • Yes and this is verified on my license
  • No, I have not gone through the process of becoming a 103 NP
  • Application completed and pending/in-process
  • N/A - Not CA licensed
• Are you Board Certified as a PMHNP with either the ANCC or AANP?✱

  Select...YesNoIn Process
• Which state(s) do you have an active license as a PMHNP✱

  • Alaska
  • California
  • Colorado
  • Idaho
  • Oregon
  • Texas
  • Washington
  • Other
• Which state(s) do you have an active DEA?✱

  • Alaska
  • California
  • Colorado
  • Idaho
  • Oregon
  • Texas
  • Washington
  • None
  • In process for one of the above states
• What diagnosis have you worked with within the past 12 months?✱

  • Neurodevelopmental Disorders
  • Schizophrenia spectrum and other psychotic disorders
  • Bipolar and related disorders
  • Depressive disorders
  • Anxiety disorders
  • Obsessive-compulsive and related disorders
  • Trauma- and stressor-related disorders
  • Dissociative disorders
  • Somatic symptom and related disorders
  • Feeding and eating disorders
  • Sleep–wake disorders
  • Sexual dysfunctions
  • Gender dysphoria
  • Disruptive, impulse-control, and conduct disorders
  • Substance-related and addictive disorders
  • Neurocognitive disorders
  • Personality disorders
• What age groups do you work with?✱

  • Children
  • Adolescents
  • Adults
  • Geriatric
• Which settings have you worked in?✱

  • Outpatient
  • Inpatient
  • Residential Treatment
  • Telehealth
  • Private Practice
  • Community Health
  • Non-Profit
  • Rehabilitation
  • Correctional
• Cover Letter/Additional Documents (optional)

  Upload file
• Licensure - Optional

  Upload file

Bilingual

• Please select any languages you speak, read, and write fluently✱

  Select...Mandarin ChineseSpanishHindiArabicBengaliPortugueseRussianJapanesePunjabi/LahndaGermanItalianFrenchOtherN/A

Demographic Survey for Headlight

We invite you to complete this optional survey to help us evaluate our diversity and inclusion efforts. Submission of the information on this form is strictly voluntary and refusal to provide it will not subject you to any adverse treatment or affect your job application. Information obtained will be kept separate from your name or job application. This information will be kept secure and confidential and will be used solely to evaluate our diversity and inclusion efforts.

• I identify my ethnicity as

  Select all that apply

  • White / Caucasian
  • Hispanic, Latino, or Spanish origin
  • Black or African American
  • Asian
  • Native Hawaiian or other Pacific Islander
  • Indigenous Peoples, First Nations, Native American, or Alaska Native
  • Middle Eastern or North African
  • Some other race, ethnicity, or origin
• Are you Hispanic/Latino?
  • Yes
  • No
  • Decline to Self Identify
• What gender do you identify as?
  • Female
  • Male
  • Non-binary
  • Genderqueer
  • Genderfulid
  • Agender
  • Cisgender
  • Transgender
  • Gender-neutral
  • Gender nonbinary
  • Intergender
  • Polygender
  • Genderflux
  • Androgynous
• Veteran Status
  • I am not a protected veteran
  • I identify as one or more of the classifications of a protected veteran
  • I do not wish to answer
• Disability Status
  • Yes, I have a disability, or have had one in the past
  • No, I do not have a disability and have not had one in the past
  • I do not want to answer

• By applying for this position, your data will be processed as per Headlight's .