Step 1 of 4 25% Application Type*Select Application TypeEAP AffiliateTrauma SpecialistTrainerCrisis ResponderProvider InformationName* First Name Last Name Work Phone*Cell Phone*Secure Email* Primary Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon State/Province Zip/Postal Code Gender (optional)Choose GenderFemaleMaleNeutralOptional Demographic Information Our clients often ask for a provider that meets specific demographics within the following categories. Please note, that your response to the below is voluntary and your response, or lack of response, will not affect your application being approved or denied.If you are willing, please identify your ethnicity and/or nationality:If you are willing, please identify your religious background:If you are willing, please identify your sexual orientation:LanguagesPlease list any additional languages you can conduct sessions in: Able to conduct sessions utilizing American Sign Language: Practice InformationSame as my primary address Practice Type*GroupIndividualBusiness Name of Practice*Business Service Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number for Referrals*Secure Fax Number for ReferralsWebsiteAdd Additional Service Location Business Service Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone Number for ReferralsBilling Address If Different from above Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business AttributesThis office complies with the Americans with Disability Act (ADA).YesNoThis business is owned by a woman.YesNoThis business is owned by a member of a minority group.YesNoThis business is owned by a U.S. Military Veteran.YesNoThis business is owned by a service-disabled U.S. Military Veteran.YesNoThis business identifies as a small disadvantaged business.YesNoThis business is a member of the Alliance for Strong Families and Communities.YesNoThis business is a 501c3 human service nonprofit.YesNoDo you practice out of your home?YesNoDo you offer evening appointments?YesNoDo you offer weekend appointments?YesNoAre you able to return client phone calls within 1 business day?YesNoAre you able to offer (client may decline appointment) an appointment within two business days?YesNoPractice Primary EAP Contact PersonSame as my primary info Name* First Name Last Name Primary Phone*Cell Phone (not given to clients only used for emergencies such as office phone outage, etc.)Secure Email* Provider ExperiencePlease select demographics/areas that you have experience working with. African American Asian Hispanic LGBT Veteran/Military Substance Abuse Grief/Loss Child/Adolescent/Parenting Domestic Abuse Couples Critical Incident Stress Debriefing (CISD) Sexual Abuse EMDR General Faith Based Counseling Higher Education Law Enforcement Mediation Telephonic EAP Counseling Video EAP Counseling First Responders Religion-Specific Faith Based Counseling (Identify)Experience in Specialty AreasI am experienced in facilitating EAP Orientations/Trainings.YesNoI am experienced in providing Critical Incident Stress Debriefings (on-site).YesNoI am experienced in providing services for employer mandated substance abuse cases.YesNo Provider License InformationRequirement: FEI Affiliates must have independent mental health licensure to practice within their state and are not under any type of supervision.License Number*License Type*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificExpiration Date* MM DD YYYY Total Years Post-Masters Experience*Professional Liability InsuranceRequirement: FEI affiliates must hold coverage at a minimum of $1 million per occurrence and $3 million per aggregateName of Liability Carrier*Policy number*Effective date* MM DD YYYY Expiration date* MM DD YYYY $ Limit per Occurrence*$ Limit Aggregate*EAP ExperienceRequirement: FEI affiliates must have at least 1 year of EAP specific experience to qualify for our network.Total years of EAP experience*I am qualified to provide broad-brush mental health and substance abuse assessment.YesNoI am qualified and experienced in providing solution-focused counseling.YesNoI am able to assess and refer (not treat) anyone at least 5 years of age and older. Parents may be included in session.YesNoI am able to work with individuals, couples and families.YesNoI comply with state and federal laws including HIPPA.YesNoEAPs & Insurances PanelsPlease list EAPs and insurances panels that you currently provide, or in the past have provided services for.Are you a Certified Employee Assistance Professional (CEAP)?YesNoCEAP Certificate #Expiration Date MM DD YYYY Are you an Employee Assistance Specialist – Clinical (EAS-C)?YesNoEAS-C Certificate #Expiration Date MM DD YYYY Substance Abuse Specialist (optional)Substance Abuse Specialists skills and expertise are utilized in the employer mandated referral process, when substance abuse is involved.Do you have an Alcohol & Drug Certification?YesNoState IssuedAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCertification #Expiration Date MM DD YYYY As a Substance Abuse Specialist, I meet the criteria below and have the ability to demonstrate the following:I have a minimum of 3000 supervised hours of experience providing direct services for alcohol and/or drug-related disorders obtained at a State-Certified clinic or facility.YesNoI regularly, as a part of the certification for my primary license, participate in continuing education directly related to AODA issues.YesNoI regularly provide direct services to clients whose primary presenting problem is alcohol or other drug abuse.YesNoApproximately 25% of my practice consists of clients whose presenting problem is drug and/or alcohol-related.YesNoI have expertise in conducting a general, standardized drug and alcohol assessment.YesNoI am able to provide education regarding the drug or alcohol itself, the effects of the substance in question and substance use in the workplace, including impact on business and safety issues.YesNoI have the ability to determine the most appropriate course of treatment and refer to the appropriate resources if treatment is warranted.YesNoMilitary and Veteran Specialist (optional)FEI is in an excellent position to respond in a proactive manner to the needs of this special population. One part of that response involves identifying employees and family members affected by either their own, or a family member’s military service. Those identified complete an assessment tailored to issues specific to military personnel, and are referred to a provider in FEI ’s network who has the knowledge, skills and expertise to respond to the unique needs of military and veteran family needs. As a Military and Veteran Specialist, I am able to demonstrate the following:I have experience counseling military personnel, veterans and their family members.YesNoI am current with evidence-based clinical practices regarding psychological health needs of military personnel, veterans, and their families and utilizes best practices within the limits of EAP.YesNoI understand military culture, the deployment cycle, combat trauma, and the constellation of common issues for military personnel including suicidal risk, substance abuse, sleep problems, and blast-related Traumatic Brain Injury (TBI).YesNoI have the skills to engage, assess and intervene with military and veteran personnel and military family members.YesNoI am able to identify public and private resources in the community available to individuals affected by military service.YesNoCritical Incident Stress Debriefing Response ExperienceThrough which organization did you receive training/certification in Critical Incident Stress Debriefing?*(i.e., AAETS, FAA, HRM, ICISF, NOVA, Red Cross, other certification)Name of Training Course*Date of Training* MM DD YYYY Number of years of Critical Incident Stress Debriefing experience:*How many traumatic incidents have you responded to in the past two years?*Identify the types of traumatic incidents and workplace traumas that you have responded to:* Robbery Domestic Violence Death of employee Workplace Violence Natural disasters Suicide Downsizing Workplace accident Identify any other relevant experience or training you have in the area of trauma response or work*Crisis Responder ApplicationPreferred Contract:IndividualGroupPlease select all crisis responder roles you are applying for: Family Information Counselor (FIC) Family Information Counselor Remote Option (FIC-Remote) Family Assistance Representative (FAR) Crisis Support Coordinator (CSC) I have Critical Incident Stress Debriefing (CISD) Training/CertificationYesNoI have EMDR Training/CertificationYesNoOther Related Skills/Training/Certifications:I have a valid passportYesNoPassport Country of Issue:Select CountryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweTraining ExperienceDo you have experience providing EAP training?*YesNoYears of training experience:Hours spent training annually:Please describe your training philosophy:Preferred areas of training:Audience:CliniciansColleges/UniversitiesProfessional ConferencesCorporationsColleaguesEmployeesSupervisors/Executive LeadershipLaw EnforcementGovernment EntitiesPlease select the types of audiences for whom you have previously trained/presented (please select all that apply).Technological Background:EmailPowerPointLaptop ComputersWebinarsVideo ConferencingPlease select the technological areas that you have had experience with (please select all that apply).Employee Wellness SeminarsAnger ManagementBalancing Care Giving Duties for Elder ParentsBeyond Stress: Recognizing the Signs of DepressionBuilding Personal ResilienceDealing with Difficult PeopleEAP Overview and Awareness TrainingEffective CommunicationMaintaining a Healthy LifestyleMaintaining Health RelationshipsManaging StressPlanning for Your RetirementPower and Control in Personal RelationshipsRaising Responsible ChildrenRecognizing the Signs of Adolescent Eating DisordersRecognizing the Signs of Adolescent Substance AbuseSubstance Abuse AwarenessThe Challenges of Balancing Work and Your Personal LifeThe Survivors Syndrome: Dealing with Organizational ChangeTime ManagementFEI Behavioral Health offers the following seminars to our clients. These seminars typically run between 45-60 minutes in length. Please select the topics that you have had experience presenting on.Management Training SessionsEffective Communications for ManagersLeading During Difficult TimesManaging Difficult NewsManaging Difficult PeopleManaging Difficult SituationsMotivating Your EmployeesRecognizing Signs of Domestic ViolenceStress and Depression in the WorkplaceSubstance Abuse Awareness for LeadersThe Impact of Trauma on Employees and Their ProductivityTime Management for LeadersWorkplace Violence PreventionYour EAP as a Management ToolFEI Behavioral Health offers the following seminars to the leadership groups of our clients. These sessions can run anywhere from a couple of hours to an all-day session, depending on the needs of the client. Please select the topics that you have had experience presenting on.ReferencesReference 1Organizational Name:Contact Name:Contact Email: Training Date: MM DD YYYY Training Topic:Reference 2Organizational Name:Contact Name:Contact Email: Training Date: MM DD YYYY Training Topic:Reference 3Organizational Name:Contact Name:Contact Email: Training Date: MM DD YYYY Training Topic: DocumentsIn order to process your application, please upload, fax to: 414-359-6519 or e-mail to network@feinet.com, the following documents:License:Liability Insurance:Resume:W-9:Additional License/Certification:Additional License/Certification:Additional License/Certification: Agreement and Electronic SignatureMy electronic signature and submission certifies the following:That I have provided complete, true and correct information and that I meet and will comply with the requirements of this position.YesNoI will not disclose any client-related information to anyone other than FEI Behavioral Health.YesNoI am licensed to provide mental health services independently in my state.YesNoI have a minimum of 1-year experience providing EAP services.YesNoMy practice is in compliance with HIPAA.YesNoI understand and will comply with all FEI requirements for designation as an EAP Affiliate. Some of these requirements include: Offer of an appointment within 2 business days for routine appointments. Clients at least 5 years of age (while I may not specialize in working with children, I will provide broad EAP assessment and referral, and I may choose to require the participation of a child’s parent(s) in the session). FEI requirements for designation as an EAP Affiliate agreementYesNoBy your signature below, you indicate your understanding of, and agreement with the following: I hereby certify that all the responses and information provided pursuant to the above are complete, true and correct, to the best of my knowledge. If approved as a FEI Crisis Responder, I agree to utilize any FEI standard materials according to their intended use, and will not release them further without written authorization from FEI Behavioral Health. I understand that I am representing FEI Behavioral Health whenever I am responding to a crisis activation.By your signature below, you indicate your understanding of, and agreement with the following: I hereby certify that all the responses and information provided pursuant to the above are complete, true and correct, to the best of my knowledge. If approved as a FEI Trauma Specialist, I agree to utilize any FEI standard materials according to their intended use, and will not release them further without written authorization from FEI Behavioral Health. I understand that I am representing FEI Behavioral Health whenever I am responding to a critical incident stress debriefing on their behalf.By your signature below, you indicate your understanding of, and agreement with the following: I hereby certify that all the responses and information provided pursuant to the above are complete, true and correct, to the best of my knowledge. I agree that, if approved as a FEI Trainer, I will implement training programs for FEI and only with FEI approval. I agree to utilize any FEI standard training materials according to their intended use and will not release them further without written authorization from FEI Behavioral Health. I understand that I am representing FEI Behavioral Health whenever I am implementing a FEI Training Program.Signature*Date* MM DD YYYY EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
