First name

Middle name

Last name

Address 1

Address 2

City

State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

ZIP

Phone:

(Home)

(Work)

(Mobile)

(Pager)

E-mail

Educational Background

Other specialized training or education, e.g., DBT, CBT, IPT, etc. (do not include any crisis response training in this section)

NPI#

(if applicable)

CAQH#

(if applicable)

In what languages are you fluent?

Crisis Response training

(Note: you will be required to include certificates of completion for any trainings listed here)

List any additional crisis response related training that you have received (specialty areas such as response for children, communities, business, bio-terrorism, etc.)

How many years have you provided crisis response services (telephone, on-site (indicate which type(s) of responses you have provided)?

Approximately how many incidents (indicate whether telephone support and/or onsite) have you been called upon to provide response services?

Have you provided crisis response services in business settings for Employee Assistance Programs (EAP), Human Resources(HR) or other corporate departments?

Yes
No

Have you ever provided crisis response services for other crisis management organizations or groups, e.g. (Red Cross, Green Cross, CMI, CCN, etc.)?

Yes
No

Do you currently provide crisis response services for Red Cross, Green Cross, CCN, etc.?

Yes
No

Professional licenses or certifications

Type of license

(eg — social work, psychology, counseling, etc)

States in which you are licensed:
(press CTRL for multiple selections)

License #:

Expiration:

Name of malpractice insurance company:

Amount of coverage (1 million/3 million minimum required)

Expiration:

Is your malpractice coverage for you as an individual? Or agency?

Statement of agreement

By submitting this application online, I understand that my application to become a Support Consultant for Supportive Solutions, Inc. does not guarantee inclusion in this network. It is my understanding that direct admittance into this network will be based on my experience providing crisis response services in a business setting, my previous training, clearance of my license and background check. I also understand that if I am not accepted due to limited experience or training, that training/mentoring or coaching options might be offered to support my entry into this network.

If I am accepted into the network, I understand that I will be required to participate in continuing education provided to the Support Consultant Community.

I verify that all information that I have provided in this application packet is true to the best of my knowledge.

I have read and agree to the above statement.