EAP Contract Counselor Agreement for EAS
Contract Counselor Name:
Business Name:
Address:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Effective Start Date:
-
Month
-
Day
Year
Date
Counselor Qualifications:
LPC
LPC-S
LICSW
LMSW
LMFT
Other
License Number:
Expiration Date:
-
Month
-
Day
Year
Date
Liability Insurance:
Policy Number:
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Scope of Services:
Anxiety/Panic Attacks
Depression
Grief
Trauma/PTSD
Brief Counseling (EAP)
Crisis Intervention
On-Site Critical Incident Response
Workshops/Trainings
Life Transitions
Coping Skills
Addiction
Work Related Stress
Anger Management
OCD
Personal Growth
Chronic Health Issues
Psychoeducation
Family
Adults
Children
Teens
Relationship Issues
Couples
ADHD/ADD
Eating Disorders
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Additional Compensation
Crisis Response: TBA
Training/Workshop: TBA
Confidentiality & Compliance
Counselor agrees to comply with:
*HIPAA
*Alabama confidentiality laws
*Mandatory reporting
*Professional ethical codes
*EAP Provider policies
Immediate Termination Grounds
*Loss of Licensure
*Ethical Violations
*Breach Of Contract
*Failure to maintain Insurance
Other:
*Counselor expected to keep their own notes
*Bi-Weekly payments
*Copies needed: DL, Professional License, Professional Liability Insurance
Signature
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