|KPA-CAP Provider Registration Form|
By providing my information below to the KPA-CAP subcommittee, I agree to participate as a Colleague Assistance Program provider who is willing to serve as a provider of psychological services to colleagues in distress. I agree to adhere to the following guidelines:
-maintain a valid license to practice psychology in Kentucky
-offer one free consultation session to KPA members to assess:
-offer services to non KPA psychologists although the one free session will not be expected
-accept at least one request per year
-supply the number of clients seen to the KPA-CAP committee annually
-notify the CAP committee when no longer able to remain on the provider list
I understand that:
-My name be listed on the KPA-CAP page of the KPA website to indicate that I am a willing provider of KPA-CAP services.
-Neither KPA nor the KPA-CAP committee will be making specific referrals. All contacts and resulting therapeutic relationships will be initiated by the client directly with the potential provider, thus insuring confidentiality.
-Neither KPA nor the KPA-CAP committee will hold any legal responsibility or professional liability if a conflict with a client occurs. My professional liability insurance will be expected to cover any unresolved complaints.
-Neither KPA nor the KPA-CAP committee are affiliated with the Kentucky Licensing Board in any way. KPA-CAP does not accept mandated referrals by the state board and KPA-CAP providers do NOT share any information with the state board.
-There is detailed information about CAPs in general and KPA-CAP participation on the KPA-CAP page of the KPA website which I may access if desired.