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.
