Diakon Inroads EAP Affiliate Application

Basic Information
Affiliate/Group Name:
Address:
Address:
City, State ZIP: ,   
Company Phone:
Alternate Phone:
Fax:
Contact Person:
Email:
Direct Phone:
Provider Names:
Do you currently contract directly with companies to provide EAP services?
Are you currently an affiliate/sub-contractor to provide EAP services?
Would you be willing to conduct EAP training/orientation to our companies?
Is there a SAP available to conduct DOT evaluations?
(Please note SAP next to providers name above)
Will you consider providing CISD or CISD Counseling?
Will 'non-urgent' appointments be available within three working days?
What types of appointments do you offer?

How quickly will you be able to schedule 'urgent' appointments? Hours
Who answers your phones?



What other languages your providers may assist?
How will you handle appointments during vacation/sick time?

Emergency Contact

For Emergency Purposes Only May We Have the Following Phone Numbers:
Local Police:
Closest ER:
D & A Crisis:
24 Hr/MH Crisis:
Child Abuse Protection Agency:
Domestic Violence Shelter:
Other:

Areas Of Specialty
Addiction:












Mental Health:


















Other Services:




















Diakon Lutheran Social Ministries