• Join Our Network

    Thank you for your interest in joining the First Sun EAP Provider Network. We thoughtfully review each application to ensure a strong fit for our EAP members and providers.

  • QUALIFICATIONS

    Face-to-Face Counselor

    • Master’s Degree 
    • Fully licensed in the state where you provide services
    • Malpractice insurance in an amount of not less than one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) per aggregate
    • Minimum of three years’ experience in a clinical setting post full licensure

    Video, Chat, Message Counseling

    • HIPAA-compliant video counseling platform
    • Business Associate Agreement (BAA) from a platform verifying that the platform is HIPAA compliant
    • Malpractice insurance that includes video counseling

    CREDENTIALING
    We use credentialing to verify your professional credentials against our criteria. Here’s what you need to upload to this form. 

    • A copy of your malpractice insurance
    • A copy of the BAA from your video counseling platform
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Provider Practice Information

  • Is your office ADA compliant?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Check all modalities you offer to your clients for therapy:*
  • Are you interested in becoming one of our critical incident providers?*
  • Are you interested in becoming one of our network trainers?*

  • Demographics

  • Date of Birth
     - -
    2 digit day, 2 digit month, 4 digit year
  • Are you fluent in English*
  • Other languages you are fluent in
  • Gender*

  • Licensure and Certification

  • Check all that apply:*

  • Malpractice / Ethics Questionnaire

  • 1. Have you ever been convicted of a crime involving sex-related or child/elder abuse-related offenses?*
  • 2. Have you ever been convicted of any other crime (other than minor traffic violations)?*
  • 3. Do you have any pending misdemeanor or felony charges?*
  • 4. In the past three years, has your license to practice in any jurisdiction ever been voluntarily or involuntarily denied, restricted, suspended, challenged, revoked, conditioned or otherwise limited?*
  • 5. In the past three years and up to and including the present, have you had any ongoing physical or mental impairment or condition that would make you unable, with or without reasonable accommodation, to perform the essential functions of a practitioner in your area of practice, or unable to perform those essential functions without a direct threat to the health and safety of others?*
  • 6. Considering the essential functions of a practitioner in your area of practice. In the past three years and up to and including the present, have you suffered from any communicable health condition that could pose a significant health risk and safety risk to your clients?*
  • 7. Have you ever had an incident that resulted in an allegation of sexual, child or elder abuse?*
  • 7a. Was a claim made against you? ((If yes, please submit details at the end of the document.)*
  • 7b. Was the case settled?
  • 7c. Was it taken to trial?*
  • 8. Have you ever been sanctioned for an ethical violation? (If yes, please submit details at the end of the document.)*
  • 8a. Was a claim made against you? ((If yes, please submit details at the end of the document.)*
  • 8b. Was the case settled?
  • 8c. Was it taken to trial?*
  • 8d. Were there any recommendations or restrictions made for you?
  • 9. In the past three years, have you had a history of chemical dependency or substance abuse that might affect your ability to competently and safely perform the essential functions of a practitioner in your area of practice?*
  • 10. In the past three years, have you had or do you have any mental or physical condition, or do you take any medications that might affect your ability to competently and safely perform the essential functions of a practitioner in your area of practice?*
  • 11. In the past three years, has any malpractice carrier ever made an out-of-court settlement or paid a judgment of a medical malpractice claim on your behalf, or have you ever been named in a malpractice suit, settled, active or dismissed?*
  • 12. In the past three years, has your professional liability insurer placed conditions or restrictions on your coverage of ability to obtain coverage?*
  • 13. Are you aware of any potential malpractice suits that may be filed against you?*
  • 14. Have you ever been trained in the area of sexual, child and elder abuse in aspects such as how to recognize the signs and what to do if a client/child/aging person reports that someone has abused him or her?*
  • 15. Are you supervised on a regular basis to monitor your relationship and professional services with clients/children/aging persons?*
  • 16. Do you participate in peer supervision or consult with peers when needed?*
  • 17. If you are without supervision resources, do you agree to contact First SunEAP so that we can work with you to provide peer supervision or to findadequate supervision resources?*
  • 18. Do you agree to contact First Sun EAP should you be charged with or convicted of any ethical violation or crime, including sex-related or child/elder abuse- related offenses?*
  • 19. Do you have malpractice insurance? (If yes, please attach evidence thereof and return with this form.)*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: