Becoming An EAP Provider

 
 

An Empathia Affiliate must have a minimum of a Master’s degree in a human services related field, be independently licensed in the state in which he or she practices, have at least 5 years of post-graduate clinical experience, and have extensive experience in the EAP field.

To be considered for Empathia’s network, either click here to complete the application online or download a hard copy form from this website. You will need the following information:

  • Tax ID
  • Clinic Addresses
  • NPI, License, and Certifications Numbers
  • Dates of Issue and Expiration for Licenses and Certifications
  • Liability Insurer with Coverage Limits and Expiration Date

Upon receipt of your application, we will add the information about your practice to our resource directory. We will then contact you directly if services are needed in your area.

Affiliate Application

W-9 Form

Empathia Affiliate Manual

Manual Acknowledgment Form