Provider Demographic Information

Before beginning the application process to join our EAP provider network, please review the Network Eligibility Requirements listed below. If you do not meet the minimum criteria, please do not complete this application until you meet these requirements. Thank you for your interest in joining our network.

Network Eligibility Requirements

1. Master's Level graduate degree or higher in counseling, social work, psychology, or related mental health profession
2. MINIMUM of 3 years post-graduate mental health counseling experience
3. MINIMUM of 3 years with EAP clinical functions, including:
   • Assessment
   • Short-term solution focused counseling
   • Assisting with work/life issues that impact job performance
   • Connecting clients to resources and long term care
   • Assessing and referring clients with alcohol and substance abuse issues
4. Licensed within the state to practice independently, without supervision
5. Carry minimum Malpractice and Liability Insurance Coverage of $1,000,000 per occurrence and $3,000,000 aggregate
6. A valid e-mail address to be used for business purposes is required to participate in the Concern EAP Network. This e-mail address will receive secure, encrypted e-mails containing client authorization details.

Note: Per standard EAP practices, we respectfully request that our providers return all telephone calls within one (1) business day, offer appointments for routine referrals within three (3) business days, and offer appointments for urgent referrals within one (1) business day. For the convenience of our clients, if you do not have any openings for new appointments within five (5) business days or longer, please notify us so that we may place a temporary hold on new referrals to your practice. Thank you.

Required Documents

1. All current licenses and certifications
2. Copy of current professional liability insurance face sheet
3. Completed W-9 form (W-9 must show name registered with IRS and billing address)
4. Resume (work history must show 3 years post masters clinical experience)