Becoming an ESI Employee Assistance
Group Service Provider

Mandatory Requirements


  • State Licensure as a Behavioral Health Professional with at least a Master’s Degree.
  • Minimum and current Malpractice Liability Insurance Coverage of $1 million /$3 million
  • Empanelment with at least one major/area Behavioral Health Insurance plan.

Please complete and sign the Provider Application
[Click Here to Fill Out the Provider Application]

Please review and fill out the following for SMS Texting (not required to be a Provider)
[SMS Texting Terms and Conditions]
[Texting Letter PDF]
[Texting Letter Word Doc]

Service Provider Application Form and include:

  • Professional Malpractice Liability Insurance Face Sheet
  • State Licensure or Registration with Expiration Date
  • Resume
  • W9 Tax ID Form

Please return completed application with supporting documentation to our Corporate

Office: ESI Employee Assistance Group


Fax: 585-593-6311

Provider Information

If you are a licensed counselor that would like to become a contracted provider for ESI Employee Assistance Group, please complete the following form for recommendation. Our Network Development Specialist will get in touch with you about contracting with ESI.

Request a Quote