Wellspring EAP Provider Application Questionnaire

Basic Info

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* Last Name

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* First Name

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* Middle Name/Initial

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* Have you updated your contact/practice/specialty information (via this online questionnaire) with Wellspring EAP in the last 6 months?

I am a new provider/applying to be a provider

No

Not sure

Yes

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* If you are new to Wellspring EAP, did a client refer you to us?

Yes

No

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* What is the intake/referral number of the client or their first name & last initial? (Please do not include PHI)

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* If you were referred to us by a specific client, are you interested in receiving referrals from us for other clients in the future who may be a fit for your practice? (You can accept or decline any referral we outreach about and can change whether or not you would like to receive referrals from us at any time.)

Yes

No

Unsure at this time.

14% of survey complete.