American Substance Abuse Profesionals

ASAP Online Network Application

Practice/Personal Data

Applicant Name:

Credentials (Including Highest Degree Obtained):

SSN:

Group or Agency Name:

Tax ID #:

Email:

Primary Telephone #:

Secondary Telephone #:

Pager:

Mobile:

Home Telephone:

Fax:

Mailing Address / Office Address(es):

In-Home Office? Yes       No

Handicapped Accessible? Yes       No

Office Hours:
Mon:      Tue:      Wed:
Thu:      Fri:      Sat:

Please list cities/towns within a reasonable travel distance of your office

SAP Experience

Please describe your substance abuse treatment experience including when and where your experiences took place:

Have you provided SAP evaluations for DOT mandated employees? How many SAP evaluations have you provided?

Have you taken the required DOT SAP Qualification Training and passed a DOT SAP Qualification Examination? If not, when do you anticipate completing these qualifications?

If you provide SAP evaluations, how do you stay updated on the DOT rules on drugs and alcohol?

Have you had experience providing the DOT mandated supervisory training? If yes, please describe.

Additional competencies or special skills (including languages spoken):

Affiliations

If applicable, Please list the names and location for the following facilities:

Hospitals

Substance Abuse Treatment Centers:

EAPs: (For whom do you, or have you, performed EAP Services?)

Other SAP Vendors: (For whom do you, or have you performed SAP services?

Professional History Statement

In accordance with the National Committee for Quality Assurance, ASAP requires your response to the questions in this section. If you answer yes to any of these questions, please include a written explanation of the circumstances surrounding each item on item 16 in this section.

1. Has your professional license/certification ever been denied, revoked, suspended, or limited?
Yes       No

2. Is there any action pending to revoke, suspend, or limit your professional license/certification?
Yes       No

3. Have you ever been denied professional liability insurance or has your insurance ever been canceled or denied renewal?
Yes       No

4. Has your Certified Employee Assistance Professional (CEAP) certification or other certification ever been revoked, suspended, or limited?
Yes       No

5. Do you have any ongoing physical or mental impairment or condition which would make you unable, with or without reasonable accommodation, to perform the essential functions of a practitioner in your area of practice, or unable to perform those functions without a direct threat to the health and safety of others?
Yes       No

6. Is there any legal action pending related to your practice?
Yes       No

7. Have you ever been the subject of disciplinary proceedings by any professional association or organization (i.e. state licensing board; county, state, or national professional society; hospital, medical, or clinical staff)?
Yes       No

8. Do you currently use illegal drugs or abuse drugs or alcohol?
Yes       No

9. Do you have a history of chemical dependency or substance abuse that might adversely affect your ability to competently and safely perform the essential function of a practitioner in your area of practice?
Yes       No

10. Have you ever been convicted of a felony or involved in charges relating to moral or ethical turpitude?
Yes       No

11. Have you ever been denied liability insurance or has your insurance ever been canceled or denied renewal?
Yes       No

12. Have you ever been named as a defendant in a criminal proceeding?
Yes       No

13. Have you had any malpractice claims during the past 5 years?
Yes       No

14. Have you ever been a defendant in any lawsuit involving your practice where there has been an award or payment of $25,000 or more?
Yes       No

15. Have you had any malpractice claims where there has been an award of payment of $25,000 or more?
Yes       No

16. If you answered "Yes" to any of the above questions (1-15), please provide an explanation describing the circumstances surrounding each item

How Did you hear about ASAP?

By clicking the "submit" button below, I hereby attest that all the information enclosed is complete and accurate and fairly represents my clinical qualifications. Furthermore, I attest that all the enclosed is truthful information. I authorize American Substance Abuse Professionals, Inc. to consult with or request from any third party who may have information bearing on any subject addressed by this application and to inspect or obtain records or documents of said third party that may be relevant to this application. I also authorize any third parties to release information to American Substance Abuse Professionals, Inc. and any authorized representative upon request. I hereby release American Substance Abuse Professionals, Inc. and any representatives from any liability for any such reports or documents, which hold information pertinent to this application. I hereby authorize and request any educational institutions or programs, professional review organizations, employers, peer review bodies, insurance carriers or others to disclose to American Substance Abuse Professionals, Inc. upon request information and documentation as will reasonably assist American Substance Abuse Professionals, Inc. in its efforts to determine my professional and personal qualifications for the network position for which I am applying.