SAP Referral Services
The gold standard in performing Substance Abuse and Behavioral Health Evaluations nationwide
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Washington
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Home Phone Number
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Emergency Contact Name
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First
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Email
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Website (if not applicable write N/A)
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General Information
Credentials
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Do you have credentials to upload?
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Upload Your Credentials
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Max. file size: 512 MB.
Please Attach Your Resume/CV
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Max. file size: 512 MB.
Office Hours (Check All That Apply)
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Thursday Office Hours
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Sunday Office Hours
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List Any Additional Languages Spoken (if not applicable write N/A)
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Are you FMCSA Clearinghouse registered?
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If yes, attach copy of CH registration page
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Max. file size: 512 MB.
Are you CISM trained or certified?
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If yes, by what authority?
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How many CISMs have you performed in the past year?
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Professional Liability Insurance
Have you ever been denied?
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Have you ever been cancelled?
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Professional Licenses or Certificates
Have you ever been denied?
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Has it ever been suspended?
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Has it ever been revoked?
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Has it ever been limited?
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If you answered yes to any of the above questions, please attach a written explanation and any supporting documents.
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Other
Have you ever been involved in any disciplinary action brought about by any patient/client, professional organization or association?
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Are you currently involved in any professionally related legal litigation?
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Any pending litigation?
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Have you ever been convicted of a felony?
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Have you ever been charged or convicted of a drug or alcohol related offense?
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No
Have you ever had a malpractice claim filed against you?
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If you answered yes to any of the above questions, please attach a written explanation and any supporting documents.
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Max. file size: 512 MB.
Attestation
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I agree
I hereby attest that all of the disclosed information is true and accurate. I hereby expressly give authorization to SAP Referral Services, LLC and any of its members to make contact with any party listed on this application, including but not limited to educational institutions, licensing organizations, insurance carriers or any other entity supplied herein. I understand that if any of this information is deemed inaccurate or untruthful, SAP Referral Services, LLC or any of its members may terminate this relationship without notice.
I hereby agree to indemnify, defend and hold harmless SAP Referral Services, LLC, its members and employees against any and all liabilities, loss, damage, claim or cause of action related to any direct or indirect services provided.
By typing your name below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By typing your name below you consent to be legally bound by this Agreement's terms and conditions.
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