Patient Portal
24 Hour Crisis Hotline: (800) 615-0122 or (304) 425-0122
Employment Application



Are you under 18 Years of age?

Are you over 65 years of age?

Are you a citizen of the U.S.?

If not a citizen, do you have permission to remain permanently in U.S.?
(You will be required to present documents)

If employed, can you submit proof of age?

If employed, can you submit proof of citizenship?

Have you previously been employed with southern highlands?

Do you have a relative working for Southern highlands?

Have you ever been convicted of a drug related charge?

Have you ever been convicted of a felony?


Did you graduate from high school or achieve a GED?
Name of university, college, trade, business or correspondence school completed Specialty/Major Degree Earned/
Date Earned



List all current and valid licenses you hold (i.e., drivers, social work, nursing, etc.)
Type License Number Expiration Date


List all employment beginning with the most recent job and working back.
May we contact this employer to obtain a reference?
May we contact this employer to obtain a reference?
May we contact this employer to obtain a reference?


(Do not include former employers or relatives)

Name and Occupation Address Phone

I authorize a criminal investigation to be completed. I also understand that continued employment is contingent upon a satisfactory report.

I understand that as a condition for my application to be considered, I will agree to undergo drug screening. I understand that if my test results are positive, I shall not be considered further by SHCMHC.

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts is cause for dismissal

West Virginia is an employment at will state meaning that either the employer or the employee can terminate the relationship at any time for any reason.

By typing my name in the signature field below and clicking "Submit your Application" I agree that my electronic signature will act as my handwirtten signature.

What's Going On?

Automated Appointment Reminders

Southern Highlands is excited to announce that effective Friday June 23,2017 we will be utilizing an automated call/ text service to remind consumers of your upcoming appointments. You will receive a call or text three days prior to your appointment and another reminder one day before your scheduled appointment. The service will provide prompts if you need to cancel or re-schedule your appointment. The first time receiving a text message you will be prompted to opt in authorizing text reminders. Please make sure the front desk or your case manager has your correct phone number.