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Associate Application

Name

Phone Number

- -

Fax Number

- -

E-mail Address

Office Address

Address

City

County

State

Zip

Second Office Address or Mailing Address

Address

City

County

State

Zip

1. How long have you been in the counseling field?

years

2. What masters degress have you earned?

MS Counseling/Rehabilitation
MA Counseling/Rehabiliation
MHS - Masters in Health Science
MSW - Masters in Social Work
PhD in Psychology
Other -

3. What license types do you hold?

LCSW
LCPC
LCP
LMFT

LMHP
PA
LP
Other -

4. Are you a certified Drug and Alcohol Counselor?

Yes No
State of Certification:
State Certification Number:
State Certification Number::

5. Have you completed SAP training requirements as specified by the DOT and are
qualified to complete an SAP evaluation?

Yes No

6. Are you a CEAP?

Yes No

Year first certified:

7. Have you worked with other EAPs?

Yes No

If yes, please list them:

8. Do you have specific training in Critical Incident Stress Debriefing?

Yes No

If yes, please list training and previous experience:

9. Have you conducted EAP training?

Yes No

If yes, please list training and previous experience:

10. What are you clinical specialties?

AIDS/HIV
Substance Abuse
Anger Management
ADHD/ADD
Bipolar Disorder
Chronic/Terminal Illness
Domestic Violence
Depression
Dual Diagnosis
Eating Disorder

Family Therapy
Gay/Lesbian Issues
Grief/Loss
Learning Disorders
Marital/Couples Therapy
Obsessive/Compulsive Disorder
PTSD
Sexual Abuse
Stess Management
Other -

11. What is your office location?

Professional Building
Social Service Agency
Home Office
Church
Other -

12. Is your office handicap accessible?

Yes No

13. Do ou have evening and/or weekend hours available on a consistent basis for EAP clients?

Yes No

14. What languages do you conduct counseling in?

English
Spanish
Other
If other, please list: