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Employee Assistance Program (EAP) Application

Provider Info
Please enter your degree.
Licensure #1
Licensure #2
Licensure #3
Documents Needed
Areas of Speciality
Please select all specialties that apply to your practice, if you have more than one please select "Please click here to add another specialty":
Specialty
Specialized Services
Languages
Age Groups
Ethnic Heritage
In accordance with the provisions of Title VI of the Civil Rights Act of 1964, New Directions does not discriminate on the basis of race, color, or national origin. Please be aware that this information in beneficial to our members as some members feel more comfortable with a provider of the same ethnicity or cultural background.
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Provider Practice Information

Please include the following information for all practices which you may be providing services. 
Primary Address
Please do not place a - in your Tax ID number
Please list your SSN or your TIN for which you are billing, on your W-9. A W-9 cannot be accepted listing both, it has to be one. If you need a new form, it can be downloaded here: https://www.irs.gov/pub/irs-pdf/fw9.pdf
Primary Schedule
Billing Address
Secondary Address(es)
Please do not put a - in your Tax ID number.
Please list your SSN or your TIN for which you are billing, on your W-9. A W-9 cannot be accepted listing both, it has to be one. 
Secondary Schedule
Twenty- Four Hour Phone Coverage
Twenty-Four (24) hour phone coverage is a requirement for all EAP providers. 24-hour coverage means that you or another clinician will be available (at least by phone) in the event of an emergency after hours. Requesting to have the client call a local or national crisis line meets criteria; 911 would not qualify. 
Additional Information
Please answer the following questions completely. If you answer "yes" to any question, please provide a detailed description, including current disposition, in the text field below the question. 
Acknowledgement

New Directions
PO Box 6729 | Leawood, KS 66206-0729 United States
https://www.ndbh.com/ | providerrelations@ndbh.com
Florida providers (866) 730-5006 | All other providers (888) 611-6285