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KPA-CAP Provider Registration Form
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Provider Agreement:

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:

--the potential match of the relationship

--negotiate a fee and payment details

--discuss treatment goals

--address confidentiality issues

-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.

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