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Inova Employee Assistance Program: Affiliate Interest/Update Registration Form

  
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Date (mm/dd/yy)
*
Full Name (as on your current state license):
*
Work e-mail
*
Daytime Phone
*
Current State License
*
Minimum $1M/$3M unrestricted malpractice (individual/group coverage/both)
*
Malpractice claim(s) during the past 5 years
*
Length of time doing EAP: 
Years:
*
Months:
*
Do you provide short term therapy?

List 2 or 3 EAPs you have experience with as a contracted affiliate:

1
2
3
CEAP certified:
If not, master's degree in counseling:
Skill Sets (check all that apply):










Number of hours available per week:
How did you hear about us?

Service Site Locations and Type (for one or more sites)

Location 1
5-digit zip code:
City:
Type:

Location 2
5-digit zip code:
City: 
Type:

Location 3
5-digit zip code:
City: 
Type:

Location 4
5-digit zip code:
City: 
Type:

Location 5
5-digit zip code:
City: 
Type:

Expected range of fees paid:
For one (1) clinical hour: 
For one (1) training hour:
SUBMIT