Empathia EAP Affiliate Application

Fill out the spaces below, print it, and mail it to us
Please be sure to attach all additional requested material as indicated within this application

Background Information
 
First Name
      
Middle Name
      
Last Name
 
 
Social Security Number
   
National Practitioner ID
   
Yrs. in practice
   
Yrs. post-masters clinical Exp
   
Date of Birth
   
Gender
MF
   

 
 
License Class (license MUST be for Independent Practice)
MFT PC Psychiatrist Psychologist SW ARNP    
License Type (text as designated by the State on the license)
 
 
License Number    
Lic. State      
Expiration Date    
Highest Degree
      
Degree School

 
 
Office Information (please attach additional copies of this page for each practice address)
 
Practice Address (Include Ste # if applicable)
  
City
  
State
  
Zip
  
State County
 
 
Cross Street/Landmark
  
Secure Primary Phone #    
  
Home Phone #
  
Secure Alternate Phone #
  

 
 

Primary Secure FAX #      
Secure TTY/TTD #            
(Hearing Impaired)  

24/7 Access #          
  
24/7 Access Type
(e.g. Answering Service, Cell Phone, Pager)
  
 
 
Secure Email Address
  
Provider/Clinic Website
  

 
 
 
Tax ID (if applicable for this practice location)
  
Office is handicap
accessible Yes No    
Office is close to public
transportation Yes No    
Office is within 25 miles of a
military base Yes No

 
 
 
Billing/Mailing Address (if different than the practice address)    
  
City
  
State
  
Zip
  

 
 
Group Practice Name (If applicable)    
  
Contact name if a Group Practice
  
Contact # if a Group Practice
  
 
General range of hours you are, or can be, available at this address. (Show only one range/day, whole hours (e.g. From 9 To 5). Break and exception detail is not required.
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
From To From To From To From To From To From To From To
 
Additional Office Attributes
 
1. Complies with federal, state/provincial, and local legal requirements governing public accessibility, health,
and safety. YesNo
2. This office is safe YesNo
 
 
3. This office is clean YesNo
4. This office is free of fire hazards YesNo

 
 
5. This office is smoke free YesNo
6. This office is professional YesNo
 
 
7. This office is child friendly meaning, "The waiting area does not present risk of injury by sharp objects, choking toys or poisons to children. Perpetrators will not have access to children in the waiting area. Rules on child supervision such as all kids must be supervised by an adult are communicated to customers. A corner of the waiting room has child-sized furniture and toys (optional). Having family friendly office hours." YesNo
 
 
8. Equipped with security devices, including immediate security linkage in spaces where clients are seen
face-to-face. YesNo
9. Procedures assure that all buildings, grounds, and facilities are safe and secure for clients and personnel
24 hours/day YesNo
 
 
10. Procedure requires that all visitors present identification and sign-in at this office YesNo
11. A Fire Emergency Plan is posted in a visible location in this office YesNo

 
 
12. Regularly scheduled fire and evacuation drills are conducted at this office YesNo
 
 
13. This office is located in a home. (Please include and label photographs of the parking area; walkway between the parking area and the entrance [and exit if separated from the entrance]; exterior and interior of the entrance; hallways(s) from the entrance to the reception area and client meeting area; reception area; client meeting area; restrooms(s); hallways from the reception and client meeting areas to the restroom(s); if exit is separate from entrance, the hallway(s) from the client meeting area to the exit and the interior and exterior of the exit.) YesNo
 
 
14. This office is located in a religious institution. (Please include and label photographs of the parking area; walkway between the parking area and the entrance [and exit if separate from the entrance]; exterior and interior of the entrance; hallway(s) from the entrance to the reception area and client meeting area; reception area; client meeting area; restroom(s); hallways from the reception and client meeting areas to the restrooms; if exit is separate from entrance, the hallway(s) from the client meeting areas to the exit and the interior and exterior of the exit.) YesNo
 
 
15. Please attach an explanation of how confidentiality is assured if this office is located in a home or religious institution in 13/14 above. YesNo
16. Is your practice/organization at least 51% owned and 100% controlled and managed by a Minority, Woman, Service-Disabled Veteran, Vietnam Era Veteran, or Person with Disability? YesNo

 
 
Liability Insurance Information
 
Name of liability carrier
  
Policy Number
  
Effective Date   
  
Expiration Date
  
 
$ Limit per occurrence
  
$ Limit aggregate
  
Please attach a current copy of the Policy Factsheet with
limits and expiration dates. Group policies should include the names
of individual members. Minimum required is $ 1M/ $ 3M
 
Disclosure
 
If you answer YES to any of the following questions, provide: (1) a detailed explanation of your involvement, (2) the date the action was inititated, (3) the current status, including any final outcome, (4) amount of judgement/settlement or adverse decision, AND (5) a copy of any court order, consent order and findings, settlement agreement or other documentation regrding the current status or final resolution for each matter. If a matter is pending, include a letter from your attorney providing detailed information regarding current status of the matter and copies of any related documentaiton such as an indictment, statement of charges, Summons & Complain, answer, etc.
 
 
1. Have you ever been convicted of a misdemeanor related to your professional functions? YesNo
 
 
2. Have you ever been charged or convicted of a felony in any state? YesNo
 
 
3. Have you ever been investigated by any professional or licensure board, professional association, private payor, state or federal regulatory agency, or other authority? YesNo
 
 
4. Has your clinical license, certification, or ability to practice in any jurisdiction ever been stipulated, denied, restricted, suspended, reduced, revoked, not renewed, placed on probation, or otherwise limited in any way by a licensing agency or any other regulatory bodies? YesNo
 
 
5. Have you ever voluntarily relinquished your professional license, certification or other authority to practice for any reason, including as an alternative to disciplinary action? YesNo
 
 
6. Are you aware of any formal disciplinary or criminal charges pending against you? YesNo
 
 
7. Are you aware of any complaints against you filed with any licensing, certification, or other regulatory body? YesNo
 
 
8. Has it ever been determined that you have operated outside the recognized boundaries of your
professional competencies? YesNo
 
 
9. Has your employment, hospital privileges, managed care organization or EAP participation, or other privileges or participation status ever been denied, restricted, suspended, reduced, revoked, not renewed, placed on probation or otherwise
limited in any way? YesNo
 
 
10. Have you ever been involuntarily terminated from professional employment or a hospital staff, or, terminated by a managed care organization, EAP or any other organization that granted you privileges or participation status? YesNo
 
 
11. Have you ever resigned with knowledge of an investigation about you by a professional employer, hospital staff, managed care organization, EAP or any other organization that granted you privileges or participation status? YesNo
 
 
12. Are you aware of any disciplinary actions that have been initiated against you by a professional employer, hospital staff, managed care organization, EAP or any other organization that granted you privileges or participation status? YesNo
 
 
13. Are you aware of any complaints against you filed with a professional employer, hospital staff, managed care organization, EAP or any other organization that granted you privileges or participation status? YesNo
 
 
14. Are you now or have you ever been sanctioned or excluded from federal, state or local government programs, including but not limited to Medicare and Medicaid? YesNo
 
 
15. Have you ever been expelled from or disciplined by any professional association or organization not included
in any other question? YesNo
 
 
16. Do you have any physical or mental condition, treated or untreated, which in any way impairs your ability to practice to the fullest extent of your licensure and qualification or in any way poses a risk of harm to your clients? YesNo
 
 
17. Are you currently engaged in the illegal use or abuse of drugs or controlled substances? YesNo
 
 
18. Have any malpractice suits, professional liability suits, arbitration or other proceedings ever been inistituted against you? YesNo
 
 
19. Have you or anyone insuring you or otherwise acting on your behalf settled a claim of error or omission relating to your clinical practice? YesNo
 
 
20. Has a professional liability carrier ever denied, limited, not renewed or canceled your coverage? YesNo
 
 
21. Have you ever had a non-professional relationship with a client or former client that was sexual in nature or otherwise in violation of any ethical rules of your profession? YesNo
 
 
Optional, Voluntary, and Not Required
 
The following information regarding sexual orientatation, religious affiliation, and race/ethnic group is not used for purposes of denying an application for participation. Often clients will ask for a counselor who meets a specific preference within one of the following categories. If your application is approved, and you provide this information, your response will be entered into our database so that you can be identified if a client requests a counselor who meets a specific category. Any responses you provide or your decision to not provide this information will not in any way, be the basis for denying your application for participation.
 
 
Are you willing to identify your sexual orientation in our database for clients requesting an EAP counselor with your specific orientation?
BisexualGayTransgender
Are you willing to identify your religious background in our database for clients requesting an EAP counselor with your specific religious background?
CatholicismChristianity
Eastern ReligionJudaismIslam

 
 
Are you willing to identify your ethnic background in our database for clients requesting an EAP counselor with your specific background?
African AmericanArab/Arabian
Asian,PacificCaucasianHispanic
JewishNative AmericanOther
Are you willing to identify your military experience in our database for clients requesting your background? YesNo
If so, are you a Veteran? YesNo
 
Practice Overview
 
Practice Description (Please enter up to 50 words describing your practice.)
 
Please list all your membership organizations that require adherence to a professional code of ethics? (please attach a copy of memberships)
 
 
Alcohol & Drug Certification: National State Type Lic/Cert # Year Expiration
 
 
 
Do you work in a clinical practice    
for a minimum of ten hours
per week?Yes No      
Supervision/consultation hours received    
per month (number)   
Do you keep records of all training/education you
receive that can be made available to us
and/or external reviewers upon request?Yes No

 
 
Crisis Response, SAP and Training Qualifications
 
Do you have formal training and/or a certification in Trauma Response Services
(i.e. AAETS, FAA, HRM, ICISF, NOVA, Red Cross, Other Certification? If yes, attach latest proof of trainings/certificates. Yes No      
Number of years onsite Trauma Response Service experience    
 
 
Number of onsite Trauma Responses completed within the past two years    
Types of Trauma Response Services you have performed? Robbery Death of Employee Downsizing Natural Disaster Suicide Terrorism Other    

 
 
Ability to be onsite to provide services within 24-72 hours? Yes No      
Please list national networks for which you are a crisis consultant.    
 
 
Are you a qualified Substance Abuse Professional (SAP) under Department of Transportation (DOT) regulations of 1/1/04? If yes, please explain your experience and include documentation of training and test completed. YesNo

 
 
Do you have experience providing EAP training? Yes No      
Are you available to provide EAP training? Yes No      
Years of training experience
Hours of training you provide per month
 
 
Type of trainings delivered: Coaching Stress Management Wellness Work-Life Balance Other
Audience: Employees Executive Managment HR Staff Union Stewards Other

 
 
EAP Experience
 
 
1. I have experience providing
Employee Assistance counseling Yes No      
2. Total Years EAP Experience    
 
 
3. Percent of practice currently delivering EAP services    
as a provider or affiliate    
4. I am qualified and experienced in providing solution-focused
counseling Yes No

 
 
5. I am qualified to provide general assessments, short-term problem-resolution counseling, and/or referrals:
        Mental Health Yes No
        Relationships, Family & Children Within Family Yes No
        Alcohol/Drug Addiction Yes No
 
 
6. I am experienced in identifying and resolving workplace     
problems that may be cause or exacerbated
by an employee's personal
or work life Yes No      
7. I am experienced in helping employees understand and resolve
conflict at work    

 
 
8. I have experience and understanding of dual client
relationships where one is simultaneously serving
both the client, recipient of sessions, and the client company,       
payer of the service Yes No      
9. I have knowledge and experience with assessing and
managing high-risk situations (e.g. suicidal, homicidal,
self-injury)    
 
 
10. I am experienced in providing services for work-mandated     
cases Yes No      
11. I am experienced in providing drug free workplace
services Yes No      

 
 
Please list EAPs where you have been or for which you are providing services. (include dates and length of services provided)
 
 
Are you skilled in providing assessments to employees who have tested positive for substance abuse? Do you feel confident making treatment recommendations based upon your assessment? Yes No
 
 
Years worked in an outpatient/private practice substance abuse treatment setting Percent of practice in substance abuse
Years worked in an inpatient substance abuse treatment setting Percent of practice in substance abuse
 
 
After providing an EAP assessment, you may need to make a referral for a client. Are you comfortable facilitating a referral for the client by: 1) Contacting the insurance carrier to determine in-network provider options, 2) Interviewing referral options as needed, 3) Referring the client to a specific provider and 4) Contacting that provider to pass on your assessment information (with a client release)? Yes No
 
 
Insurance Plan Information
 
Please note which insurance plans you currently accept. other:
Aetna Cigna Humana PacifiCare Value Options
APS First Health Magellan Prudential  
Blue Cross Guardian Managed Health Network TRICARE  
Blue Shield Horizon Humana United Behavioral Health  
 
References (Outside current practice. At least one reference from an EAP provider/professional preferred.)
 
Name & Title: Name & Title:
Agency: Agency:
Phone: Phone:
Relationship to Applicant: Relationship to Applicant:
 
Additional Practice Information
 
How would you rate your overall familiarity with local            
community resources? Excellent Good Fair
Do you maintain a listing of local
community resources? Yes No
 
 
Are you able to return client phone calls   
within 1 business day? Yes No
Are you able to offer a routine appointment   
within 3 business days? Yes No
Are you able to offer an urgent appointment
within 1 business day? Yes No

 
 
Certified Employee Assistance Professional (CEAP) Yes No
 
Membership #: Year: Expiration:
 
Treatment Specialties
ACOA/Codependency Family Post-Traumatic Stress Disorder
ADD/ADHD Fertility Psychological Testing
Adjustment Disorders Financial Relationship/Intimacy/Commun
Adoption Gambling Sexual Abuse/Rape/Incest
Anger Mgmt. GLBT Sexual Compulsivity
Anxiety Grief/Loss/Bereavement Sleep Disorders
Career Couns./Professional Devel. Legal Smoking Control/Cessation
Chronic Illness Mediation, including Divorce Spiritual/Pastoral Counseling
Cpls./Marital Medical Issues Stress Management
Depression Mood Disorders Substance Abuse
Disability OCD Trauma/Abuse
Domestic Violence Parenting Women's Issues
Eating Disorders Perpetrators
Executive Coaching Personality Disorders
Other:
 
 
Treatment Approach
Bio/Neuro - Feedback Brief Therapy COG Behavior Therapy EMDR
Family Systems Group Hypnosis Psychodynamic
Psychoeducational Rational Emotive Therapy Solution Focused
Other:
 
 
Client Age Child Below 6     Child 6 - 12     Adolescent     Adult     Geriatric
 
 
Client Demographics You Are Experienced In Serving
African American Asian American Caucasian Christian Gay & Lesbian Latino American Military
Other:
 
 
Languages spoken other than English
American Sign Language Cantonese Creole French Japanese
Mandarin Polish Russian Spanish Vietnamese
Other:
 
 
Prescribe medications Yes No   If yes,DEA#:
 
 
I certify that all information provided in this application is true and correct to the best of my knowledge and belief. I authorize emindhealth, Inc. to verify my license, malpractice coverage and highest degree, as well as additional information included in this application, with all appropriate issuing organizations. I understand that filling out this application does not mean that I will be accepted into the emindhealth, Inc. Affiliate Network.
 
 
 
 
Applicant Name (Print)                                                  
Applicant Signature                                                  
Date
 
 
PLEASE ENCLOSE THE FOLLOWING INFORMATION.
  • Current resume/curriculum vitae (c.v.)
  • Certificate of insurance and copy of license
  • Completed W-9 form
  • Clinic brochure/information and/or business card
 Thank you for filling out this application. Please mail it to:
Empathia, Inc. Provider Relations
N17 W24100 Riverwood Drive, Suite 300
Waukesha, WI 53188
Save time: Fax to 262-523-0175