Provider Network Application

Please select all that you would like to apply for: Please select all that you would like to apply for: EAP Affiliate Trauma Specialist ¹ Crisis Responder ² Trainer

First Name

Last Name

Work Phone

Cell Phone

Secure Email

Street Address

City

State/Province State/Province *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Zip Code

Country

Gender

Sexual Orientation

Ethnicity and/or Nationality

Religious Background

Are you able to conduct sessions utilizing American Sign Language? Are you able to conduct sessions utilizing American Sign Language? Yes No

List any additional languages you are able to conduct sessions in:

Business Name of Practice

Practice Type Practice Type *GroupIndividual

Phone Number for Referrals

Secure Fax Number for Referrals

Website

Is the business service address the same as the primary address above? Is the business service address the same as the primary address above? Yes No

Business Street Address

Business City

Business State/Province Business State/Province *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Business Zip Code

Business Country

Is there an additional service location? Is there an additional service location? Yes No

Additional Location Street Address

Additional Location City

Additional Location State/Province Additional Location State/Province *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Additional Location Zip Code

Additional Location Country

Is the billing address the same as an address above? Is the billing address the same as an address above? Yes, Same as Primary Address Yes, Same as Business Service Address No, Use a Different Address

Billing Street Address

Billing City

Billing State/Province Billing State/Province *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Billing Zip Code

Billing Country

Does this office comply with the Americans with Disability Act (ADA)? Does this office comply with the Americans with Disability Act (ADA)? Yes No

Is this business owned by a woman? Is this business owned by a woman? Yes No

Is this business owned by a member of a minority group? Is this business owned by a member of a minority group? Yes No

Is this business owned by a U.S. military veteran? Is this business owned by a U.S. military veteran? Yes No

Is this business owned by a service-disabled U.S. military veteran? Is this business owned by a service-disabled U.S. military veteran? Yes No

Is this business a disability owned business? Is this business a disability owned business? Yes No

Do you practice out of your home? Do you practice out of your home? Yes No

Do you offer evening appointments? Do you offer evening appointments? Yes No

Do you offer weekend appointments? Do you offer weekend appointments? Yes No

Are you able to return client phone calls within one business day? Are you able to return client phone calls within one business day? Yes No

Are you able to offer (client may decline) an appointment within two business days? Are you able to offer (client may decline) an appointment within two business days? Yes No

Is the primary EAP contact's information the same as above? Is the primary EAP contact's information the same as above? Yes No

Primary Contact First Name

Primary Contact Last Name

Primary Contact Work Phone

Primary Contact Cell Phone (Not given to clients. Only used for emergencies such as office phone outage, etc.)

Primary Contact Secure Email

Please select specializations that you have experience working with: Please select specializations that you have experience working with: ADD/ADHD Addiction: Non-Chemical Adolescents: 13-17 Years Adults Anger Management Anxiety Autism/Aspergers Career Coaching Career/Work Stress CBT Chemical Health Assessment Children: 5 Years and Under Children: 6-8 Years Children: 9-12 Years Christian Counseling DBT Depression Domestic Violence: Perpetrator Domestic Violence: Victim Eating Disorders Elder Care Issues EMDR Families Formal Management Referrals Gambling Addiction Generational Trauma Grief/Loss Learning Disabilities LGBTQ Medical Issues/Chronic Illness Men's Issues Multicultural Concerns OCD (Obsessive/Compulsive Disorder) Parenting Personality Disorders PTSD Race-Based Traumatic Stress Race Related Stress Relationship Issues Retirement Self-Harm Sex & Intimacy Sleep Disorders Spiritual Counseling Sport Performance Stress Management Substance Abuse Tobacco/Smoking Cessation Trauma Trauma: Sexual/Physical Women's Issues

Identify any religion-specific or faith-based counseling experience:

Are you experienced in facilitating EAP orientations/trainings? Are you experienced in facilitating EAP orientations/trainings? Yes No

Are you experienced in providing onsite Critical Incident Stress Debriefings? Are you experienced in providing onsite Critical Incident Stress Debriefings? Yes No

Are you experienced in providing services for employer mandated substance abuse cases? Are you experienced in providing services for employer mandated substance abuse cases? Yes No

License Number

License Type

License State/Province License State/Province *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Expiration Date

Total Years of Post-Masters Experience

Name of Liability Carrier

Policy Number

Effective Date

Expiration Date

Dollar Limit per Occurrence

Dollar Limit Aggregate

Total Years of EAP Experience

Are you qualified to provide broad-brush mental health and substance abuse assessment? Are you qualified to provide broad-brush mental health and substance abuse assessment? Yes No

Are you qualified and experienced in providing solution-focused counseling? Are you qualified and experienced in providing solution-focused counseling? Yes No

Are you able to assess and refer (not treat) anyone at least five years of age and older. Parents may be included in session. Are you able to assess and refer (not treat) anyone at least five years of age and older. Parents may be included in session. Yes No

Are you able to work with individuals, couples and families? Are you able to work with individuals, couples and families? Yes No

Do you comply with state and federal laws including HIPAA? Do you comply with state and federal laws including HIPAA? Yes No

List EAPs and insurances panels that you currently provide, or in the past have provided services for:

Are you a Certified Employee Assistance Professional (CEAP)? Are you a Certified Employee Assistance Professional (CEAP)? Yes No

CEAP Certificate Number

Expiration Date

Are you an Employee Assistance Specialist – Clinical (EAS-C)? Are you an Employee Assistance Specialist – Clinical (EAS-C)? Yes No

EAS-C Certificate Number

Expiration Date

Do you have an Alcohol & Drug Certification? Do you have an Alcohol & Drug Certification? Yes No

State Issued State Issued *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Certification Number

Expiration Date

Do you have a minimum of 3,000 supervised hours of experience providing direct services for alcohol and/or drug-related disorders obtained at a state-certified clinic or facility? Do you have a minimum of 3,000 supervised hours of experience providing direct services for alcohol and/or drug-related disorders obtained at a state-certified clinic or facility? Yes No

Do you regularly, as a part of the certification for your primary license, participate in continuing education directly related to AODA issues? Do you regularly, as a part of the certification for your primary license, participate in continuing education directly related to AODA issues? Yes No

Do you regularly provide direct services to clients whose primary presenting problem is alcohol or other drug abuse? Do you regularly provide direct services to clients whose primary presenting problem is alcohol or other drug abuse? Yes No

Does approximately 25% of your practice consist of clients whose presenting problem is drug and/or alcohol-related? Does approximately 25% of your practice consist of clients whose presenting problem is drug and/or alcohol-related? Yes No

Do you have expertise in conducting a general, standardized drug and alcohol assessment? Do you have expertise in conducting a general, standardized drug and alcohol assessment? Yes No

Are you able to provide education regarding the drug or alcohol itself, the effects of the substance in question and substance use in the workplace, including impact on business and safety issues? Are you able to provide education regarding the drug or alcohol itself, the effects of the substance in question and substance use in the workplace, including impact on business and safety issues? Yes No

Do you have the ability to determine the most appropriate course of treatment and refer to the appropriate resources if treatment is warranted? Do you have the ability to determine the most appropriate course of treatment and refer to the appropriate resources if treatment is warranted? Yes No

Do you have experience counseling military personnel, veterans and their family members? Do you have experience counseling military personnel, veterans and their family members? Yes No

Are you current with evidence-based clinical practices regarding psychological health needs of military personnel, veterans, and their families and utilize best practices within the limits of EAP? Are you current with evidence-based clinical practices regarding psychological health needs of military personnel, veterans, and their families and utilize best practices within the limits of EAP? Yes No

Do you understand military culture, the deployment cycle, combat trauma, and the constellation of common issues for military personnel including suicidal risk, substance abuse, sleep problems, and blast-related Traumatic Brain Injury (TBI)? Do you understand military culture, the deployment cycle, combat trauma, and the constellation of common issues for military personnel including suicidal risk, substance abuse, sleep problems, and blast-related Traumatic Brain Injury (TBI)? Yes No

Do you have the skills to engage, assess and intervene with military and veteran personnel and military family members? Do you have the skills to engage, assess and intervene with military and veteran personnel and military family members? Yes No

Are you able to identify public and private resources in the community available to individuals affected by military service? Are you able to identify public and private resources in the community available to individuals affected by military service? Yes No

Through which organization did you receive training/certification in Critical Incident Stress Debriefing? (i.e., AAETS, FAA, HRM, ICISF, NOVA, Red Cross, other certification)

Name of Training Course

Date of Training

How many years of Critical Incident Stress Debriefing experience do you have?

How many group debriefings have you responded to in the past two years?

Identify the types of traumatic incidents and workplace traumas that you have responded to: Identify the types of traumatic incidents and workplace traumas that you have responded to: Death of Employee Domestic Violence Downsizing Natural Disasters Robbery Suicide Workplace Accident Workplace Violence

Identify any other relevant experience or training you have in the area of trauma response or work:

Which is your preferred contract? Which is your preferred contract? Individual Group

Please select all crisis responder roles you are applying for: Please select all crisis responder roles you are applying for: Crisis Support Coordinator (CSC) Family Assistance Representative (FAR) Family Information Counselor (FIC) ¹ Family Information Counselor Remote Option (FIC-Remote) ²

Do you have Critical Incident Stress Debriefing (CISD) training/certification? Do you have Critical Incident Stress Debriefing (CISD) training/certification? Yes No

Do you have EMDR training/certification? Do you have EMDR training/certification? Yes No

Identify any other related skills/training/certifications:

Please summarize your Crisis Management and/or Critical Incident Stress Debriefing experience and background:

Do you have a valid passport? Do you have a valid passport? Yes No

Passport Country of Issue

Do you have experience providing EAP training? Do you have experience providing EAP training? Yes No

Years of Training Experience

Hours Spent Training Annually

Preferred Areas of Training

Please describe your training philosophy:

Please select the types of audiences for whom you have previously trained/presented: Please select the types of audiences for whom you have previously trained/presented: Clinicians Colleagues Colleges/Universities Corporations Employees Government Entities Law Enforcement Professional Conferences Supervisors/Executive Leadership

Please select the technological areas that you have had experience with: Please select the technological areas that you have had experience with: Email Laptop Computers PowerPoint Video Conferencing Webinars

AllOne Health offers the following seminars to our clients. These seminars typically run between 45-60 minutes in length. Please select the topics that you have had experience presenting on: AllOne Health offers the following seminars to our clients. These seminars typically run between 45-60 minutes in length. Please select the topics that you have had experience presenting on: Anger Management Balancing Care Giving Duties for Elder Parents Beyond Stress: Recognizing the Signs of Depression Building Personal Resilience Dealing with Difficult People EAP Overview and Awareness Training Effective Communication Maintaining a Healthy Lifestyle Maintaining Healthy Relationships Managing Stress Planning for Your Retirement Power and Control in Personal Relationships Raising Responsible Children Recognizing the Signs of Adolescent Eating Disorders Recognizing the Signs of Adolescent Substance Abuse Substance Abuse Awareness The Challenges of Balancing Work and Your Personal Life The Survivors Syndrome: Dealing with Organizational Change Time Management

AllOne Health offers the following seminars to the leadership groups of our clients. These sessions can run anywhere from a couple of hours to an all-day session, depending on the needs of the client. Please select the topics that you have had experience presenting on: AllOne Health offers the following seminars to the leadership groups of our clients. These sessions can run anywhere from a couple of hours to an all-day session, depending on the needs of the client. Please select the topics that you have had experience presenting on: Effective Communications for Managers Leading During Difficult Times Managing Difficult News Managing Difficult People Managing Difficult Situations Motivating Your Employees Recognizing Signs of Domestic Violence Stress and Depression in the Workplace Substance Abuse Awareness for Leaders The Impact of Trauma on Employees and Their Productivity Time Management for Leaders Workplace Violence Prevention Your EAP as a Management Tool

Organization Name

Contact Name

Contact Email

Training Date

Training Topic

Organization Name

Contact Name

Contact Email

Training Date

Training Topic

Organization Name

Contact Name

Contact Email

Training Date

Training Topic

License: Choose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, png, pdf, doc, docx. Max. file size: 1 MB

Liability Insurance: Choose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, png, pdf, doc, docx. Max. file size: 1 MB

Resume: Choose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, png, pdf, doc, docx. Max. file size: 1 MB

W-9: Choose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, png, pdf, doc, docx. Max. file size: 1 MB

Additional Licenses/Certifications: Choose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, png, pdf, doc, docx. Max. file size: 4 MB

Type Full Name to Sign Electronically

Date