Application

If you have any questions before completing the application please call 877-844-8693 x6, or email us at fieldoperations@empathia.com

Founded in 1982, Empathia is a global, full service provider of mental health and crisis management services. Empathia is focused on creating a more compassionate, caring world by delivering expert, supportive solutions to individuals, organizations, communities and beyond. Our mission is to support clients through life's challenges, from the ordinary to the unthinkable, with compassion and empathy.

If you have any questions as you complete the application, please call 877-844-8693, x6, or email fieldoperations@empathia.com. Because our network needs fluctuate, applications are considered based on experience, client volume, location and current need.

Empathia is seeking experienced professionals for the following roles (check all relevant to your application):

These individuals provide virtual and in-person services, including clinical assessment and brief supportive counseling. Minimum requirements include a master’s degree in a behavioral health field, state licensure and five years of post-master’s experience. Special consideration will be given to applicants with short-term counseling experience (e.g., employee assistance). A resume, proof of licensure and certificate of insurance must be submitted with your application. If your practice is not currently contracted with Empathia, a W-9 is also required.
This subcontractor role provides clinical assessment and brief counseling via phone, video, and chat at a rate of $55 per session. Minimum requirements include a Masters degree in a behavioral health field, state licensure and posting availability weekly on Empathia’s online calendar. A resume, proof of licensure, a W-9 and certificate of insurance must be submitted with your application.
These individuals provide onsite or virtual training to promote wellbeing and support individual or leader skill development. Minimum requirements include a bachelor’s degree and experience facilitating presentations in a professional environment. A resume must be submitted with your application. If your practice is not currently contracted with Empathia, a W-9 is also required.
These individuals provide support to those affected by a critical incident through individual and group debriefings and leader consultation to normalize reactions and emphasize resilience. Minimum requirements include a master’s degree in a behavioral health field, state licensure and (1) five years of post-master’s crisis response experience, (2) prior critical incident response training, or (3) successful completion of Empathia’s specialized crisis response training. A resume, proof of licensure and certificate of insurance must be submitted with your application. If your practice is not currently contracted with Empathia, a W-9 is also required.
Incident Response Contact Center (IRCC) Specialist
We have a temporary hiring freeze for IRCC Specialists. Please check back again.
In the immediate aftermath of a large scale event, this telephonic based role is performed virtually from your home or office using cloud and web-based tools. The Specialist processes inquiries, provides updates, offers support and coordinates logistical assistance to those directly impacted as well to concerned family members. Successful completion of a 1.5 hour online training module followed by evaluation of role performance is required before becoming part of this network. Minimum requirements for this role include a Masters degree in a human services field, licensed or certified with 5 years of crisis response experience. A resume, proof of licensure, and certificate of insurance must be submitted with your application. If your practice is not currently contracted with Empathia, a W-9 is also required.
This telephonic-based role is performed virtually from your home or office using cloud and web-based tools. The specialist fields calls and provides information to callers based off of FAQ's provided by the client organization. Successful completion of training/orientation is required before becoming part of this network. Minimum requirements for this role include a Bachelor's degree in a human services or related field or equivalent experience.
These individuals deploy to a designated Survivor & Family Assistance Center (SFAC) or Family Reunification Center (FRC) in the incident area. Representing the client organization, this role serves as a primary point of contact for survivors and families for approximately 3-7 days post-incident. Specialists provide information, support and logistical assistance to an assigned survivor or family OR support operations. Staffing generally consists of 12-hour shifts per day. Minimum requirements for this role include a master’s degree in a human services field, licensure or certification and five years of crisis response experience. A resume, proof of licensure and certificate of insurance must be submitted with your application. If your practice is not currently contracted with Empathia, a W-9 is also required.


I am a provider with an existing Empathia affiliate.
  

Documents

In order to process your application, please upload, fax (262-953-8743) or e-mail (fieldoperationsteam@empathia.com) the following documents:

License:
License:   
Additional License:
Additional License:   
Additional License:
Additional License:   
Additional License:
Additional License:   
License/Certification:
License/Certification:   
Additional License/Certification:
Additional License/Certification:   
Additional License/Certification:
Additional License/Certification:   
Additional License/Certification:
Additional License/Certification:   
Certificate of Liability Insurance:
Liability Insurance:   
If you are covered under a group insurance policy, the certificate of insurance must include your name or you need to include another document on business letterhead that indicates that you are covered on the group insurance plan.
Resume:
Resume:   
W-9:
W-9:   
Minority Owned Business Certification:
Minority Owned Business Certification:   
Disadvantaged Business Enterprises Certification:
Disadvantaged Business Enterprises Certification:   
Women-owned Business:
Women-owned Business:   
8(a) certified:
8(a) certified:   
Veteran-owned Business:
Veteran-owned Business:   
Very Small Business Enterprise:
Very Small Business Enterprise:   

Provider Info


* = required field.



First Name *
Last Name *
Primary Phone *
Secondary Phone *
Emergency Phone *
Cell Phone *
May we text you? *
  
Secure Fax Number
Secure Email *
Address *
Address 2
City *
State *
Zip *
Gender
Date of Birth *
Are you a veteran?
  
How did you hear about Empathia? *
Billing Address
Address
Address 2
City
State
Zip
Education
Highest Degree Attained *
Year degree attained *
Name on the degree *
Name of school for highest degree *
School City *
School State *

Optional
Often clients will ask for a provider who meets a specific preference within one of the following categories. Any responses you provide or your decision to not provide this information will not be the basis for denying your application.

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
If you are in a solo practice, please provide a brief bio and a photo for our online directory
Photo:
Photo:   
Brief Bio:

Practice


* = required field.



Practice Type *
Name of Practice *
Address *
City *
State *
Zip *
Office Attributes
Add additional location
Address 2
City 2
State 2
Zip 2
Office Attributes
Add additional location
Address 3
City 3
State 3
Zip 3
Office Attributes
Add additional location
Address 4
City 4
State 4
Zip 4
Office Attributes
Website
Main Contact Name of Practice
First Name
Last Name
Primary Phone
Secure Email
Cell Phone
Credentialing Contact
First Name
Last Name
Primary Phone
Secure Email
Billing Contact
First Name
Last Name
Primary Phone
Secure Email
Business Status
By checking any of the boxes below, you acknowledge that you have completed the self-certification small business concern application process and have been granted the certification by the relevant agency. Proof of certification may be mailed or uploaded.
    
    
    
    
    
    
    
    

PLEASE NOTE: In order to be included in our Supplier Diversity Program, please be sure to update your current diversity certificates annually.

Licenses

National Provider ID # *
License Number *
License Type *
If other please specify
State*
Expiration Date *
Add additional license
License 2 Number
License 2 Type
If other please specify
State
Expiration Date
Add additional license
License 3 Number
License 3 Type
If other please specify
State
Expiration Date
Add additional license
License 4 Number
License 4 Type
If other please specify
State
Expiration Date
Add additional license
License 5 Number
License 5 Type
If other please specify
State
Expiration Date
Add additional license
License 6 Number
License 6 Type
If other please specify
State
Expiration Date
Total Years Post-Masters Experience *

Experience

Client Demographics
Session Format
Treatment Approach
  

Treatment Specialties

Check all that apply

Other (Specify):

Languages

Other

Professional Liability Insurance

Policy number *
Name of Liability Carrier *
Expiration date *
Effective date *
$ Limit per Occurrence *
$ Limit Aggregate *
PREVIOUS 5 YEARS PROFESSIONAL LIABILITY INSURANCE INFORMATION ( IF DIFFERENT FROM ABOVE )
Name of Previous Liability Carrier:
Policy number
Original Effective Date:
Expiration date
Address
City
State
Zip
$ Limit per Occurrence
$ Limit Aggregate
Add additional insurance carrier
Name of Previous Liability Carrier:
Policy number
Original Effective Date:
Expiration date
Address
City
State
Zip
$ Limit per Occurrence
$ Limit Aggregate

EAP Experience

Total years of EAP counseling experience *
Percent of practice currently delivering EAP services as a provider or affiliate *
Please list EAPs where you have been or for which you are providing services (include dates and length of services provided).


Are you a Certified Employee Assistance Professional (CEAP)?
If yes, please include a copy of your certificate.
  
CEAP Certificate #
Date of Issue
Expiration Date
Are you a member of the Employee Assistance Professionals Association (EAPA)?
  

Empathia highly encourages all providers to join EAPA (Employee Assistance Professional Association). You can do so by going to eapassn.org

EAPA Membership #
Expiration Date
Do you have an Alcohol & Drug Certification?
  
State or National
Certification #
Date of Issue
Expiration Date:
Do you have coaching experience and/or training?
  
If so, please describe:
Are you able to offer an appointment within 3-5 business days?
  
Please list all your membership organizations that require adherence to a professional code of ethics.

Crisis Response Experience

Do you have formal training and/or a certification in providing Critical Incident Response Services (i.e., AAETS, FAA, HRM, ICISF, NOVA, Red Cross, other certification)?
If yes, provide latest proof of trainings/certificates.
  
Please list any formal training and date:
Certification type
Certification #
Date of Issue
Expiration Date:
Will you provide CIR services virtually?
  
Will you travel out of state to provide CIR services?
  
Do you have a passport? *
 
Emergency contact name *
Emergency contact number *
Number of years of onsite Critical Incident Response Service experience: *
Types of Critical Incident Response Services you have performed?

Training Experience

Do you have experience providing EAP training?
  
Years of training experience:
Please describe your training style:
Audience of your training (please select all that apply):
Select the words that best describe your training style:
In preparation for or during your training sessions, do you:

Ability to Perform Essential Job Functions

Are you able to perform the essential functions of a practitioner in your area of practice?
  
If no, please explain:
Do you require accommodations in order to perform these functions?
  
If yes, please explain:
Are you currently engaged in the illegal use or abuse of drugs or controlled substances?
  
If yes, please explain:
Do you have any reason to believe that you would pose a risk to the safety or well being of your patients?
  
If yes, please explain:

Disclosure

If you answer YES to any of the following questions, please provide: (1) a detailed explanation of your involvement, (2) the date the action was initiated, (3) the current status, including any final outcome, (4) amount of judgment/settlement or adverse decision, AND (5) a copy of any court order, consent order and findings, settlement agreement or other documentation regarding the current status or final resolution for each matter. If a matter is pending, include a letter from your attorney providing detailed information regarding current status of the matter and any related documentation (an indictment, statement of charges, Summons & Complaint, answer, etc.).
Have you ever been convicted of a misdemeanor related to your professional functions?
  
Have you ever been charged or convicted of a felony in any state?
  
Have you ever been investigated by any professional or licensure bo.ard, professional association, private payer, state or federal regulatory agency, or other authority?
  
Has your clinical license, certification, DEA, CDS, or ability to practice in any jurisdiction ever been stipulated, denied, restricted, suspended, reduced, revoked, not renewed, placed on probation, or otherwise limited in any way by a licensing agency or other regulatory bodies?
  
Have you ever voluntarily relinquished your professional license, certification or other authority to practice for any reason, including as an alternative to disciplinary action?
  
Are you aware of any formal disciplinary or criminal charges pending against you?
  
Are you aware of any complaints against you filed with any licensing, certification, or other regulatory body?
  
Has it ever been determined that you have operated outside the recognized boundaries of your professional competencies?
  
Has your employment, hospital privileges, managed care organization or EAP participation, or other privileges or participation status ever been denied, restricted, suspended, reduced, revoked, not renewed, placed on probation or otherwise limited in any way?
  
Have you ever been involuntarily terminated from professional employment or a hospital staff, or, terminated by a managed care organization, EAP or any other organization that granted you privileges or participation status?
  
Have you ever resigned with knowledge of an investigation about you by a professional employer, hospital staff, managed care organization, EAP or any other organization that granted you privileges or participation status?
  
Are you aware of any disciplinary actions that have been initiated against you by a professional employer, hospital staff, managed care organization, EAP or any other organization that granted you privileges or participation status?
  
Are you aware of any complaints against you filed with a professional employer, hospital staff, managed care organization, EAP or any other organization that granted you privileges or participation status?
  
Has a professional liability carrier ever denied, limited, not renewed or canceled your coverage?
  
Are you now or have you ever been sanctioned or excluded from federal, state or local government programs?
  
Have any malpractice suits, professional liability suits, arbitration or other proceedings ever been instituted against you?
  

Authorization and Release

I certify that all information provided by me in my application is current , true, correct, accurate and complete to the best of my knowledge and belief, and is furnished in good faith.
I hereby authorize the Credential Verification Organization (the CVO) to consult with any representative(s) of the medical/professional or administrative staff of any health care organizations with which I have or have had employment, practice, association or privileges, and any other organizations (including without limitation state licensing boards and the National Practitioner Data Bank) or individuals who have information bearing on my credentials, competence, professional performance, clinical skills, judgment, character and ethical qualifications, and to inspect such records which shall be material to the evaluation of my professional qualifications and competence to carry out the privileges I am requesting, as well as to my moral and ethical qualifications.
I hereby authorize any health care organizations with which I have or have had employment, practice, association or privileges, and any other organizations (including without limitation state licensing boards and the National Practitioner Data Bank) or individuals who have information bearing on my credentials, competence, professional performance, clinical skills, judgment, character and ethical qualification to provide and/or release information (both written and oral) to representatives of the Credential Verification Organization (the CVO) bearing on my credentials, competence, professional performance, clinical skills, judgment, character and ethical qualifications. Such information includes but is not limited to information regarding any and all malpractice actions, pending or final disciplinary actions and alterations in privileges, and any information with respect to whether I am able to perform the essential functions of the position for which I have applied or the privileges I have requested with or without a reasonable accommodation, according to accepted standards of professional practice and without posing a direct threat to patients or staff (including without limitation information regarding any impairment due to the use of drugs or alcohol).
I authorize and request my medical malpractice liability insurance carrier to release information to the Credential Verification Organization (the CVO) regarding any claims or actions for damages pending or closed, whether or not there has been a final disposition.
I hereby release from liability any and all individuals and organizations that, in good faith and without malice, provide information to the Credential Verification Organization (the CVO) for the purpose of verifying my background, experience, qualifications, and credentials. I also hereby release from liability the Credential Verification Organization (the CVO) for their acts performed in good faith and without malice in connection with the evaluation of my professional skills, competence, character, credentials and qualifications and the exchange of information with respect to my professional skills, competence, character, credentials and qualifications.
I agree that a photocopy of this Authorization and Release Statement will be as valid as the original, and that this Authorization and Release Statement will remain valid unless revoked by me in writing, or the date on which the Credential Verification Organization (the CVO) next conducts recredentialing.
Use your mouse/finger to sign this document.


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