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North Star Information Request

Please do not use this form, or electronic mail, to discuss your medical condition, medical history, or private health information. It is not encrypted, and we cannot guarantee your privacy if you include sensitive information about yourself.

I would like to find out more about working with the team at North Star Behavioral Health System. Please contact me with more information.

Name: __________________________
Address: __________________________
City/State/Zip: __________________________
Day Telephone: __________________________
Evening Telephone: __________________________
Best time to call: __________________________
E-mail: __________________________
I am interested in the following type of position: __________________________
I am an:
MD RN LPN LCSW MSW
Adjunct Therapist (please describe) __________________________
Other (please describe) __________________________
Additional Information: __________________________
__________________________
__________________________
__________________________
   
Please print and fax completed form to (907)279-1438. A North Star staff member will contact you. Thank you for your interest.

Hospital & Residential Treatment Centers • Anchorage: DeBarr · Bragaw; Palmer
907.258.7575 | 800.478.7575 · 24-hour crisis

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