Click here for Service Provider Application
If you are a licensed counselor that would like to become a contracted Service Provider for ESI, please complete the following form below for recommendation. Our Network Development Specialist will get in touch with you about contracting with ESI.
Our requirements to become Service Provider with ESI are as follows:
- Doctorate or masters degree in mental health specialty plus state license. OR
- Chemical Addiction Specialties with state/national certification
- Have in effect a minimum of $1,000,000/$3,000,000 malpractice liability insurance coverage
In order to complete the Service Provider Application process, you must complete and sign the
Service Provider Application. Also when submitting your application, you must include:
- A copy of the Face Sheet/Professional Liability Insurance
- A copy of State License Registration with Expiration Date
- A copy of highest degree and
- A copy of your resume.
These items can be either faxed, e-mailed or mailed to our corporate office:
ESI Employee Assistance Group
55 Chamberlain Street
Wellsville, NY 14895