Inova Employee Assistance Program
Affiliate Interest/Update Registration Form

(All fields must be filled out.)

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? yes   no

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

1

2

3

CEAP certified: yes   no

If not, master's degree in counseling: yes   no

Skill Sets (check all that apply):
Substance Abuse Professional
CID trained
CID experience
Solution-focused counseling
EAP supervisor/employee training
American sign language
Same sex partners counseling
Bilingual counseling (describe)
Faith-based counseling (describe)
Multi-cultural speciality (describe)
Disabled populations (describe)
Other (describe)

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: 
Privately rented
Group/facility site
Residence
Location 2
5-digit zip code:
City: 
Privately rented
Group/facility site
Residence
Location 3
5-digit zip code:
City: 
Privately rented
Group/facility site
Residence
Location 4
5-digit zip code:
City: 
Privately rented
Group/facility site
Residence
Location 5
5-digit zip code:
City: 
Privately rented
Group/facility site
Residence

Expected range of fees paid:

For one (1) clinical hour: 

For one (1) training hour: 

Back to main page