Prospective Network Clinician Form

To be considered for participation in EAPC’s network of EAP Clinicians, please submit the information requested below.

(*) signifies required field

*Last Name
*First Name
Group Name, if applicable
*Office Address
Suite/Bldg
*City
*State	Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
*ZIP
Mailing address (if different than office address)
*Phone
*E-mail Address
*License Type
Evening and/or Saturday Office Hours? Choose... yes no
*Able to routinely serve new EAP clients within three business days? Choose... yes no
Please Check any Areas of Expertise:
CISD DOT Qualified Substance Abuse Professional
Trainer - If yes, please indicate types of training:

Thank you for your interest in joining our clinician network.