Psychiatric Mental Health Nurse Practitioner (Remote) - Kentucky

1 - Which of the following nurse practitioner certifications have you held? Select all that apply. *
Family Nurse Practitioner Psychiatric- Mental Health Nurse Practitioner Adult- Gerontology Acute Care Nurse Practitioner Acute Care Nurse Practitioner Cardiac Nurse Practitioner Emergency Nurse Practitioner Primary Care Nurse Practitioner Gerontology Nurse Practitioner Neonatal Nurse Practitioner Pediatric Nurse Practitioner Midwife Oncology Nurse Practitioner

2 - Do you have an active DEA?  *
-- Yes No

3 - List all states that you are licensed to practice.  *
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

4 - Do you have experience working in telemedicine (please select NO if all of your Telehealth experience was temporary due to COVID.)  *
-- Yes No

5 - How many years have you been in practice? *

6 - What EMR software have you used? *
EPIC Cerner PointClickCare Meditech McKesson Athena Centricity Eclinicalworks Elation Next Gen Allscripts AdvancedMD Avatar Valiant Kareo CPRS Simple Practice 7 - What age group(s) have you cared for in the last three years: *
Infant/Toddler Adolescents Adults Geriatrics

8 - Do you acknowledge and state they are comfortable treating clients with controlled substances (schedule two) for clients diagnosed with ADHD- following evidence based guidelines. *
-- Yes No

9 - Are you a new graduate Nurse Practitioner? *
Please selectYes No New Grad PMHNP

10 - Do you acknowledge that you are comfortable and able to see clients for an initial psychiatric evaluation for 30 minutes? *
-- Yes No

11 - Do you acknowledge that you are comfortable and able to see clients for a follow up appointment for 15 minutes? *
-- Yes No

12 - Are you able to provide your schedule 30 days in advance and do you acknowledge that you need to work a minimum of three weeks before taking any time off? *
-- Yes No

13 -Do you acknowledge that you are required to work a minimum of 20 hours per week? *
-- Yes No

14 - What would you be most excited about if offered the position? Please share your strengths you will bring to the prescriber role and how your values align with our mission. *

15 - On a scale of 0 to 3, how would you rate the following: General Psychiatric Skills for all Cerebral Prescribers for Care of clients with Depressive Disorders  *
Please select0    =    No Experience/ Observed Only 1    =    Limited Experience/ Rarely Done (<6x/ year) 2    =    May Need Some Review/ Occasionally Done (1-2x/ month) 3    =    Experienced/ Frequently Done (daily or weekly)

16 - On a scale of 0 to 3, how would you rate the following: General Psychiatric Skills for all Cerebral Prescribers for Care of clients with Anxiety Disorders *
Please select0    =    No Experience/ Observed Only 1    =    Limited Experience/ Rarely Done (<6x/ year) 2    =    May Need Some Review/ Occasionally Done (1-2x/ month) 3    =    Experienced/ Frequently Done (daily or weekly)

17 - On a scale of 0 to 3, how would you rate the following: General Psychiatric Skills for all Cerebral Prescribers for Care of clients with Bipolar II Disorders *
Please select0    =    No Experience/ Observed Only 1    =    Limited Experience/ Rarely Done (<6x/ year) 2    =    May Need Some Review/ Occasionally Done (1-2x/ month) 3    =    Experienced/ Frequently Done (daily or weekly)

18 - On a scale of 0 to 3, how would you rate the following: General Psychiatric Skills for all Cerebral Prescribers for Care of clients with Suicidal Ideation/ Crisis Events *
Please select0    =    No Experience/ Observed Only 1    =    Limited Experience/ Rarely Done (<6x/ year) 2    =    May Need Some Review/ Occasionally Done (1-2x/ month) 3    =    Experienced/ Frequently Done (daily or weekly)

19 - For PMHNP's ONLY: Do you acknowledge and state they are comfortable treating bipolar one disorder under the following practice guidelines: --> Labs are ordered and monitored through our partner Lab for clients requiring lithium or depakote treatment. --> Patients receive follow up visits at minimum every six weeks. *
Please selectYes No N/A for Non-PMHNP

20 - For Non-PMHNPs only: Do you acknowledge and state they are comfortable treating clients with medication assisted weight loss under the following practice guidelines: --> Labs are ordered and monitored through our partner Lab for clients requiring GLP-1 medications. --> Client has access to a nutritionist on a monthly basis *
Please selectYes No N/A for PMHNP