Founded in 1982, Empathia is a free standing, full service, global provider of employee assistance (EAP), work/life services, workplace culture assessment and optimization, and crisis management, including responding to large scale, disastrous events. Because our network needs fluctuate, applications will be considered based on experience, client volume and location. The roles include (please check all you are applying for):
* = required field.
Date of Birth *
Billing Address If Different
Highest Degree Attained *
Year degree attained *
School City *
School State *
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
Professional Liability Insurance
PREVIOUS 5 YEARS PROFESSIONAL LIABILITY INSURANCE INFORMATION ( IF DIFFERENT FROM ABOVE )
I am qualified to provide general assessments, short-term problem-resolution counseling, and/or referrals for:
Please list EAPs where you have been or for which you are providing services (include dates and length of services provided).
State or National
How would you rate your overall familiarity with local community resources?
Please list all your membership organizations that require adherence to a professional code of ethics.
Crisis Response Experience
Types of Trauma Response Services you have performed?
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:
Empathia provides training in mindfulness for organizations and individuals. If you are interested in being a provider of these services, please indicate your experience with the following Contemplative Practices:
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.).
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?
Authorization and Release
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 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.
Use your mouse/finger to sign this document.