DEA EAP Network
Area and Remote Clinician Application

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Thank you for your interest in joining The Counseling Team International DEA Network. We take every precaution to properly qualify providers for the network to ensure they meet the growing needs of our clients and that they will have a positive experience working with us.


QUALIFICATIONS


In Person Counseling

  • Master’s Degree or higher
  • Fully licensed in the state 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

Telehealth Counseling

All of the above, plus:
  • HIPAA-compliant video counseling platform
  • Business Associate Agreement from a platform verifying the platform is HIPAA compliant
  • Malpractice insurance that includes video counseling

CREDENTIALING

Credentialing is the process we use to verify your professional credentials in conjunction with our
criteria. Here’s what you need:
  • A copy of your curriculum vitae
  • A copy of your license(s)
  • A copy of certification(s), if applicable
  • A copy of your malpractice insurance
  • Your W9 (A fillable W9 form may be downloaded at https://www.irs.gov/forms-pubs/about-form-w-9)

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Area Clinician: Conduct clinical EAP on-site services, briefings, and trainings
Clinical Briefer: Offer Clinical Briefings after traumatic incidents and other clinical onsite related services.
Trainer: Onsite and virtual trainings

Thank you for your interest. At this time we can only accept applications from providers who are authorized to work in the U.S.
Provider Contact Details





Format: ###-###-####

Format: ###-###-####

Mailing Address






Billing Address





Practice Location(s)







If you have multiple practice locations, please click link at bottom right to add another location.
Provider Profile Information


Format: MM/DD/YYYY


Licensure




Additional Licenses




Please click the link at bottom right to add another license or same license in a different state.
TCTI Clinician Questionnaire

Note: The Counseling Team International does not discriminate on the basis of race, color, sex or national origin.  Please be aware that the information below is beneficial to our clients as some may feel more comfortable with a provider with specific characteristics.




We realize you may have other areas of expertise, but have limited these to those related to First Responders.











Law Enforcement/Military Experience



Experience with First Responders 

Acronym help:
CISD = Critical Incident Stress Debriefing
ICISF = International Critical Incident Stress Foundation
CISM = Critical Incident Stress Management





Enter 0 if none


Supervisor Experience




Training Experience











Attachments


   NOTE: We require $1M per occurrence and $3M aggregate malpractice insurance.

(A fillable W9 form may be downloaded at https://www.irs.gov/forms-pubs/about-form-w-9)
Counseling Preferences




Insurance






Professional Liability













**currently - means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs'' refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22. It "does not include the use of a drug taken under supervision by a licensed healthcare professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription-controlled substances.

If you answered 'Yes" to any of the questions in this section, please explain.
Attestation
By submitting this application, I hereby attest that all the information in this application is true and accurate to the best of my knowledge, and if I am not the provider, I am authorized to submit this information on their behalf. Provider agrees they shall maintain proficiency in all specialty areas selected on this application.

I understand that First Responder Health may require documentation to verify that the provider meets the criteria outlined in this application.


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Contact Information