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Provider Application

If you are a licensed counselor that would like to become a contracted Service Provider for ESI Employee Assistance Group, please review and complete the following steps:

Our requirements to become Service Provider with ESI are as follows:

  1. State Licensure as a Doctorate or Master’s level Psychologist, Social Worker, or Counselor
  2. Certified Addiction Counselors and/or DOT Substance Abuse Professional
  3. Have in effect a minimum of $1,000,000/$3,000,000 malpractice liability insurance coverage
  4. Must be empanelled with area behavioral health insurance plans.

Please complete and sign the Service Provider Application (Click here for Service Provider Application) and include a copy of:

  • Professional Liability Insurance Face Sheet
  • State License Registration with Expiration Date
  • Certification with Expiration Date
  • Your resume

These items can be either faxed, e-mailed or mailed to our corporate office:

 ESI Employee Assistance Group
55 Chamberlain Street
Wellsville, NY 14895
Fax: 585-593-6311