Provider Network Application

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Thank you for your interest in joining the network for AllOne Health and its family of EAP/MAP/SAP companies. We look forward to working and establishing a relationship with your practice.

Once your application has been received, the Affiliate Network Management Team will review your application and if eligible, you will receive a Network Agreement via fax or email to be carefully read, signed, and returned. You will also receive an email link to register for PROVIDERfiles (electronic portal) to become eligible to receive referral opportunities. Your practice becomes fully credentialed with our EAP upon registering for PROVIDERfiles and submitting your signed agreement.

Application Type

Please select all that you would like to apply for:

¹ Trauma Specialist: short-term, on-site critical incident stress debriefing response; ² Crisis Responder: large scale activations for mass casualty/disasters (note: AllOne Health Crisis Responder training required at some point)

Provider Information

Demographic Information (Optional)
Our clients often ask for a provider that meets specific demographics within the following categories. Please note, that your response to the five fields below is voluntary and your response, or lack of response, will not affect your application being approved or denied.

Are you able to conduct sessions utilizing American Sign Language?

Practice Information

Is the business service address the same as the primary address above?

Is there an additional service location?

Is the billing address the same as an address above?

Business Attributes

Does this office comply with the Americans with Disability Act (ADA)?

Is this business owned by a woman?

Is this business owned by a member of a minority group?

Is this business owned by a U.S. military veteran?

Is this business owned by a service-disabled U.S. military veteran?

Is this business a disability owned business?

Do you practice out of your home?

Do you offer evening appointments?

Do you offer weekend appointments?

Are you able to return client phone calls within one business day?

Are you able to offer (client may decline) an appointment within two business days?

Practice Primary EAP Contact Person

Is the primary EAP contact's information the same as above?

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

Provider Experience

Please select specializations that you have experience working with:

Are you experienced in facilitating EAP orientations/trainings?

Are you experienced in providing onsite Critical Incident Stress Debriefings?

Are you experienced in providing services for employer mandated substance abuse cases?

Provider License Information

Requirement: AllOne Health affiliates must have independent mental health licensure to practice within their state and are not under any type of supervision.

Professional Liability Insurance

Requirement: AllOne Health affiliates must hold coverage at a minimum of $1 million per occurrence and $3 million per aggregate.

EAP Experience

Requirement: AllOne Health affiliates must have at least one year of EAP-specific experience to qualify for our network.

Are you qualified to provide broad-brush mental health and substance abuse assessment?

Are you qualified and experienced in providing solution-focused counseling?

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 work with individuals, couples and families?

Do you comply with state and federal laws including HIPAA?

Are you a Certified Employee Assistance Professional (CEAP)?

Are you an Employee Assistance Specialist – Clinical (EAS-C)?

Substance Abuse Specialist (Optional)

Substance Abuse Specialists skills and expertise are utilized in the employer mandated referral process, when substance abuse is involved.

Do you have an Alcohol & Drug Certification?

As a Substance Abuse Specialist, do you meet the criteria below and have the ability to demonstrate the following?

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 regularly, as a part of the certification for your primary license, participate in continuing education directly related to AODA issues?

Do you regularly provide direct services to clients whose primary presenting problem is alcohol or other drug abuse?

Does approximately 25% of your practice consist of clients whose presenting problem is drug and/or alcohol-related?

Do you have expertise in conducting a general, standardized drug and alcohol assessment?

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?

Do you have the ability to determine the most appropriate course of treatment and refer to the appropriate resources if treatment is warranted?

Military and Veteran Specialist (Optional)

AllOne Health is in an excellent position to respond in a proactive manner to the needs of this special population. One part of that response involves identifying employees and family members affected by either their own, or a family member’s military service. Those identified complete an assessment tailored to issues specific to military personnel, and are referred to a provider in AllOne Health’s network who has the knowledge, skills and expertise to respond to the unique needs of military and veteran family needs. As a Military and Veteran Specialist, are you able to demonstrate the following?

Do you have experience counseling military personnel, veterans and their family members?

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?

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 have the skills to engage, assess and intervene with military and veteran personnel and military family members?

Are you able to identify public and private resources in the community available to individuals affected by military service?

Trauma Specialist Application

Critical Incident Stress Debriefing Response Experience

(i.e., AAETS, FAA, HRM, ICISF, NOVA, Red Cross, other certification)

Identify the types of traumatic incidents and workplace traumas that you have responded to:

Crisis Responder Application

Requirement: AllOne Health Crisis Responder training is required (at some point) for all crisis responder roles.

Which is your preferred contract?

Please select all crisis responder roles you are applying for:

¹ FIC: must be within 60 miles of Milwaukee, WI; ² FIC-Remote: AllOne Health virtual call center training required

Do you have Critical Incident Stress Debriefing (CISD) training/certification?

Do you have EMDR training/certification?

Do you have a valid passport?

Training Specialist Application: Training Experience

Do you have experience providing EAP training?

Please select the types of audiences for whom you have previously trained/presented:

Please select the technological areas that you have had experience with:

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 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:

Training Reference 1

Training Reference 2

Training Reference 3

Documents
In order to process your application, please upload, fax to 339-645-2526 or email to AffiliateResponse@allonehealth.com, the following documents:

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

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

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

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

Agreement and Electronic Signature

By submitting your electronic signature below, you indicate your understanding of, and agreement with the following:

  • I hereby certify that that I have provided complete, true and correct information and that I meet and will comply with the requirements of this position.
  • I will not disclose any client-related information to anyone other than AllOne Health.
  • I am licensed to provide mental health services independently in my state.
  • I have a minimum of 1-year experience providing EAP services.
  • My practice is in compliance with HIPAA.
  • I understand and will comply with all AllOne Health requirements for designation as an EAP Affiliate. Some of these requirements include:
  • Offer of an appointment within 2 business days for routine appointments.
  • Clients at least 5 years of age (while I may not specialize in working with children, I will provide broad EAP assessment and referral, and I may choose to require the participation of a child’s parent(s) in the session).

By submitting your electronic signature below, you indicate your understanding of, and agreement with the following:

I hereby certify that all the responses and information provided pursuant to the above are complete, true and correct, to the best of my knowledge. If approved as an AllOne Health Trauma Specialist, I agree to utilize any AllOne Health standard materials according to their intended use, and will not release them further without written authorization from AllOne Health. I understand that I am representing AllOne Health whenever I am responding to a critical incident stress debriefing on their behalf.

By submitting your electronic signature below, you indicate your understanding of, and agreement with the following:

I hereby certify that all the responses and information provided pursuant to the above are complete, true and correct, to the best of my knowledge. If approved as an AllOne Health Crisis Responder, I agree to utilize any AllOne Health standard materials according to their intended use, and will not release them further without written authorization from AllOne Health. I understand that I am representing AllOne Health whenever I am responding to a crisis activation.

By submitting your electronic signature below, you indicate your understanding of, and agreement with the following:

I hereby certify that all the responses and information provided pursuant to the above are complete, true and correct, to the best of my knowledge. I agree that, if approved as an AllOne Health Trainer, I will implement training programs for AllOne Health and only with AllOne Health approval. I agree to utilize any AllOne Health standard training materials according to their intended use and will not release them further without written authorization from AllOne Health. I understand that I am representing AllOne Health whenever I am implementing an AllOne Health Training Program.