National Center for Missing & Exploited Children Family Advocacy Outreach Network Participating/Individual Agency Application

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Amber Ford
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1 National Center for Missing & Exploited Children Family Advocacy Outreach Network Participating/Individual Agency Application 699 Prince Street, Alexandria, Virginia Phone: Fax: Today s Date Name (Agency) Address Street Address City, County, State, Zip Telephone Fax Address Website Professional License Number and State Please attach copy of license Professional Liability Insurance (minimum $3,000,000/$1,000,000) Attach declarations page of current policy indicating limits and dates of coverage a. Amount of coverage b. Insurance carrier, contact person, and telephone number c. Authorization to obtain confirmation of insurance coverage from carrier Signature Page 1 of 6

2 If not included in the agency s literature, please describe the agency s experience working with reunifications, victims of sexual abuse or exploitation, domestic violence, and other forms of family trauma. (Use additional pages if necessary.) Usual and Customary Fee for Services (or Range) $ Sliding Scale (please circle) or? If yes, how is it determined? Accepted Insurances (Check all that apply) Medicare/Medicaid Medicare Only Medicaid Only Other Population(s) Chiefly Served Children 3-5 years 5-12 years Adolescents Adults Modes of Therapy Individual Family Group Other: Foreign Languages Spoken by Staff Agency Staff Demographics (optional) Some families may request a social worker or psychologist of a certain age, sex, race, or religion. It is not required, but could be helpful if you answer the following. Age and over Sex Female Male Race African American/Black White Hispanic Asian Other Religion Page 2 of 6

3 For the following questions, please use additional paper if detailed information is required. Has there ever been disciplinary action against you or the agency (including, but not limited to, reprimand, suspension or revocation of license)? Are you or the agency now the subject of any investigation or disciplinary action including, but not limited to, reprimand, suspension or revocation of license)? Have you or the agency ever been a defendant in any lawsuit where claims were asserted against you or the agency for malpractice, breach of duty, or any other action related to your or the agency s professional practice and where judgment was rendered against you or the agency? Are you or the agency presently a defendant in a lawsuit where claims are asserted against you or the agency for malpractice, breach of duty or any other action related to its professional practice? Page 3 of 6

4 I hereby certify that the information I have provided on this application is true and accurate to the best of my knowledge and belief. I authorize to inquire into the accuracy of any statements made on this application. I agree to be bound by the ethical standards of my professional association (either the National Association of Social Workers, the American Psychological Association, American Counseling Association or American Association for Marriage and Family Therapy). I have read and understand the attached Regulations and Procedures of s Family Advocacy Outreach Network and agree to abide by them. I agree to indemnify and hold harmless the Family Advocacy Outreach Network and (including its officers, directors, agents, and employees) against any and all claims for loss, damages, or costs that arise out of any referrals of clients/patients and/or treatment of clients/patients so referred. Signature Date Mail-In Instructions 1. Please mail this completed and signed application and attach a. 1 signed copy of the attached Regulations and Procedures b. 1 copy of your present license c. 1 copy of the declarations page of your current professional liability insurance policy d. 1 copy of your curriculum vitae 2. Mail to the attention of Lanae J. Holmes, LICSW, LCSW-C National Center for Missing & Exploited Children 699 Prince Street Alexandria, Virginia Page 4 of 6

5 NATIONAL CENTER FOR MISSING & EXPLOITED CHILDREN S REGULATIONS AND PROCEDURES FOR PARTICIPATION IN THE FAMILY ADVOCACY OUTREACH NETWORK The Family Advocacy Outreach Network ( FAON ) is a proactive initiative designed by the National Center for Missing and Exploited Children ( ) and administered by s Family Advocacy Division. Participants in FAON are experienced in crisis management for sexual abuse, domestic violence, and other forms of family trauma and will provide crisis management and long-term therapy as needed by families of missing and exploited children. Participants will also cooperate with s Team Adam consultants. 1 While most referrals will occur in conjunction with the deployment of a Team Adam consultant, it may be necessary to refer families who have not been assisted by Team Adam. 1. Participation in FAON is open to individual social workers, psychologists, marriage and family therapists, and counselors, as well as group practices of social workers, psychologists, marriage and family therapists, and counselors, who are licensed to practice in their state, who carry a minimum of $1 million/$3 million professional liability insurance, and who otherwise meet the eligibility requirements of FAON (collectively Participants ). If Participant s insurance coverage is claims-based, Participant must also have tail insurance to cover claims that may be brought for an incident that occurred during professional liability coverage but for which the claim was made after that coverage was terminated. 2. The Family Advocacy Division relies upon the information Participants provide in the application and supporting documentation to determine eligibility. Thus, such information must be complete, accurate, and timely. Furthermore, Participants must update their information as necessary. Failure to provide accurate and complete information may result in s excluding or removing the Participant from FAON. 3. Social worker Participants agree to abide by the Code of Ethics of the National Association of Social Workers. Psychologist Participants agree to abide by the Ethical Principles of Psychologists and Code of Conduct published by the American Psychological Association. Counselor Participants agree to abide by the Code of Ethics of the American Counselors Association. Marriage and Family Therapist Participants agree to abide by the Ethics of the American Association for Marriage and Family Therapy. A Participant s failure to comply with the applicable standards may result in a Participant s exclusion or removal from FAON. 4. A Participant may suspend or terminate his, her or its listing with FAON at any time by giving written (including ) notice to: Lanae J. Holmes Family Advocacy Division National Center for Missing and Exploited Children 699 Prince Street Alexandria, VA fax: lajones@ncmec.org 1 Team Adam sends trained, retired law-enforcement officers to the site of serious child abductions and cases of child sexual exploitation. These rapid-response specialists advise and assist local investigators, provide access to s extensive resources, and assist the victim families and media as appropriate. Page 5 of 6

6 5. The Family Advocacy Division may terminate a Participant s participation in FAON at any time, with or without cause. The Family Advocacy Division will terminate a Participant in the following circumstances: an individual Participant or one of the professionals in a group Participant loses his or her state license; Participant fails to carry the insurance coverage described in paragraph 1; and/or disciplinary action is taken against the individual Participant or one of the professionals in a group Participant by any governmental or professional agency or organization based upon a finding of a serious breach or violation of the individual or group Participant s professional and/or ethical conduct. Participant agrees to notify the Family Advocacy Division, at the address listed in paragraph 4, of any such investigation within 10 days of the initiation of the investigation. The Family Advocacy Division will keep such information confidential, and may decide, at its discretion, to suspend Participant s participation during the pendancy of the investigation. 6. Telephone referrals will be made by the Family Advocacy Division to the appropriate Participant in the family s community. If, for any reason, the Participant cannot accept the referral, or the referral appears inappropriate, the Participant should refer that person back to the Family Advocacy Division and notify the Family Advocacy Division. FAON does not guarantee that a referral will be provided to Participant. 7. Participants must be willing to work with referred parties on a pro bono basis if necessary or on a sliding-scale basis if appropriate. Arrangements for fees will be made between the Participant and the referred party. Neither nor the Family Advocacy Division is obligated to Participant for any treatment or other fees under these Regulations and Procedures. 8. Each individual Participant and each professional in each group Participant must abide by all the guidelines and rules of FAON, including these Regulations and Procedures. Individual Participants and professionals in group Participants are not, and will not under any circumstances, hold himself, herself or itself out as an employee or agent of or the Family Advocacy Division. Furthermore, no Participant, including any professional in a group Participant, will attempt to hold or the Family Advocacy Division, or any of their officers, directors, agents, or employees, liable for any claimed loss, injury, or other damage arising out of or in connection with the use of any information contained in the Participant s application or supporting documentation. Signature Date Print Name Page 6 of 6

Email (the majority of EAP Administrator use email to refer cases)

Email (the majority of EAP Administrator use email to refer cases) NASW Assurance Services, Inc. EAPrefer - Employee Assistance Program (EAP) Network Application - (Type or legibly print application in ink) Member Information NASW Member ID# Date of Birth (optional) Gender