Affiliate Change Form Carebridge Page 3
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4SECTION VIII
ADDITION of new licensing, degrees, or certifications.
(Complete only those sections pertaining to your new license, degree, or certification)
New License
New License Class (include copy of license with submission):
MFT
PC
SW
Psychologist
MHC
Are you a certified Employee Assistance Professional (CEAP)?
Alcohol & Drug Certification:
State
National
Yes
No
State: Type:
New Degree
New Degree Attained:
Year Degree Awarded:
Name of College or School:
New Certifications ‐ Crisis Response, SAP, and Training Qualifications
Are you available to provide on‐site trauma response?
Yes
No
Do you have formal training and/or a certification in Trauma Response Services
Number of years of onsite
Yes
No
(i.e. AAETS, FAA, HRM, ICISF, NOVA, Red Cross, or other certification)?
Trauma Response Service
experience:
If yes, attach latest proof of trainings/certifications.
Number of onsite Trauma Responses within
Types of Trauma Response Services you have performed:
the past two years:
Robbery
Suicide
Death of Employee
Downsizing
Terrorism
Other: _______________
Best way to reach you for immediate CISD request:
Do you have the ability to be onsite
to provide services within 24‐72 hours?
Yes
No
Are you a qualified Substance Abuse Professional (SAP) under Department of
Transportation (DOT) regulations as of 1/4/04?
Yes
No
If yes, please include documentation of training and test completed.
Do you have experience providing
Are you able to provide EAP training:
Years of Training:
Hours of training you
EAP training:
Yes
No
Yes
No
provide per month:
Types of trainings delivered:
Coaching
Stress Management
Audience:
Employees
Executive Management
Wellness
Work‐Life Balance
Other: _______________
HR Staff
Union Stewards
Other: ______________
SECTION IX
NEW Billing Address
Street Address 1:
Street Address 2:
City:
State:
Zip Code:
SECTION X
New Name or Company Name
First Name:
Middle Name:
Last Name:
Firm or Company Name:
Practice Type:
Individual
Group Social Security/EIN #:
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