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About Us
What We Do
Rehab Services
Management Services
Business Services
Outpatient Services
Careers
Jobs
Refer A Friend
Contact Us
New Facility Employee Intake
New Facility Employee Intake Form
Facility Name
*
Employee Name
*
First
Last
Discipline
*
Please select
PT
PTA
OT
COTA
SLP
CFY
Aide
Type of Position (currently)
*
Supervisor
Lead
Staff
Cell Phone Number
*
Home Phone Number
Email address
*
Home Street Address
*
Home City
*
Home State
*
Home Zip Code
*
Current Hourly Rate
*
Type of Employee
*
W2
1099
Current days and hours worked per week
*
Current Status
*
Full-Time
Part-Time
Per Diem
Number of paid days off per year (please differentiate between PTO, Holiday, Sick etc)
*
Do you currently have health insurance with your current company? (check all that apply)
*
Medical single
Medical + dependent(s)
Medical Family
No
How much do you pay for medical insurance per paycheck?
*
Do you currently have dental insurance with your current company? (check all that apply)
*
Dental single
Dental + dependent(s)
Dental Family
No
How much do you pay for dental insurance per paycheck?
*
Number of years experience
*
Number of years employed at this facility
*
Are you dual licensed?
*
Yes
No
Which states are you licensed in?
*
Do you have any preplanned days off?
*
Yes
No
Which days?
*
Will you need health insurance with Tender Touch
*
Yes
No
As of what date will you need coverage?
*
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