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Thank you for your interest in joining the Workplace Solutions EAP network. Before beginning the application process to join our EAP provider network, please review the Network Eligibility Requirements listed below. If you do not meet the minimum criteria, please do not complete this application until you meet these requirements. If you have any questions or concerns regarding Workplace Solutions application process or would like to discuss these procedures in greater detail you may do so by calling the Intake Department at 800-327-5071 during the typical daytime hours of
8:30 AM – 5:00 PM CST.
***Per standard EAP practices, we respectfully request that our active affiliates return all of our telephone
calls/emails within one (1) business day as we will consult with you regarding EAP referrals before connecting the
client. We request all affiliates who have availability to offer clients an appointment for routine referrals within three
(3) business days, and offer appointments for urgent referrals within one (1) business day. For the convenience of our
clients, if you do not have any openings for new appointments within five (5) business days or longer, please notify us so that we may immediately consult an alternative affiliate and provide options for the client as soon as possible. If you anticipate extended leave or inability to schedule with clients we ask that you notify us ahead of time so that we can update our systems to reflect your availability. If you are unable to meet these requirements, please do not
continue with the application process. ***
I hereby acknowledge that all information provided within this application is accurate and best reflects
my current experience and clinical practices. I understand that Workplace Solutions EAP does not
discriminate on the basis of race, gender, age, sexual orientation, or nation of origin. I understand that
Workplace Solutions has the right to deny my application and that the submission of this application is
not a guarantee of admittance into the Workplace Solutions affiliate network. The typical response to
hear back from a Workplace Solutions intake clinician regarding affiliate applications is within 3-5 business days.
I understand that if my application is accepted I will be asked to speak directly with a member of the
Workplace Solutions affiliate development team to review my application and clinical experience as well
as discuss case management procedures and reimbursement negotiations.
I understand that full acceptance into the Workplace Solutions affiliate network will require my review,
approval and signature on the New Affiliate Agreement and the Business Affiliate Agreement forms. I
understand that referrals are provided based on client’s location, insurance, availability, and presenting
concerns and I am not guaranteed consistent referrals.
By clicking “Submit” you affirm that all information herein is complete, true and correct to the best of your knowledge. You further acknowledge and agree that you are submitting this information voluntarily, and while all reasonable steps will be taken to maintain the confidentiality of the information submitted, you hereby release Workplace Solutions and any of its vendors, contractors, etc. from all liability in connection with the unauthorized access by third-parties.
New Affilate Application.pdf