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LifeWorks Behavioral Health Provider Form

 

The fields marked with an * below are required fields and must be completed before you can submit this form. If you have any questions while completing this form you can contact us at Central.DB@Ceridian.com or call our Provider Line at 800 290-4311, extension 5862. Leave your name and phone number and someone will return your call.
 
* New Provider Information    Updated Provider Information
 
In addition to the external behavioral health provider database, Ceridian LifeWorks also has an EAP Provider Network. Please check here, if you are interested in learning more about becoming a member of the EAP Provider Network.

YES, I'm Interested    NO
 
Provider Name *
Phone * ()-
Main Contact *
Address *
City *
State *
Zip *
Email Address *

Please check off any of the following that apply:
Addiction Disorders
Addiction treatment programs
Alcohol
Detox 
Drug Assistance 
Dual diagnosis 
Food 
Gambling 
Multiple levels of care 
National 
Polydrug 
Recovery 
Sexual addiction 

Domestic Violence
Advocacy
Anger management
Counseling 
Court manadated 
Legal advocacy 
Self-defense 

Emergency Assistance
Cash assistance
Clothing
Food 
Furniture/household items 
Mortgage assistance 
Rental/utilities assistance 
traveler's assistance 

Mental Health
Adolescent/teen
Anxiety disorder
Children 
Communication strategies 
Depression/grief 
Eating disorders 
Family 
Group 
HIV/AIDS 
Individual/relationship 
Marriage/couple 
Physical/emotional/sexual abuse 
Psychiatric treatment program 
PTSD 
Stress 
Suicide hotline 

Social Services
Adult services
burial/funeral assistance
Child abuse prevention 
Food assistance 
Foster homes 
Gang services 
Gay rights services 
Immigration services 
Information and referral 
Weatherization 
Women's center 
Youth programs 

Support Groups/training
AIDS/HIV
Assertiveness training
balancing work and family 
Chemical dependency awareness 
CISD 
Coach 
Communication skills 
Conflict resolution/mediation 
Couples/relationship training 
Dealing with difficult people 
Diversity 
Downsizing 
Drug free 
Elder care 
Employee orientation 
Executive briefing 
Holiday stress/blues 
Managing change 
Morale and productivity problems 
Parenting 
Sexual harassment 
Stress management 
Supervisor orientation 
Survivor syndrome 
Team building 
Work force alternatives 
Workplace violence 

Victim Services
Advocacy
Counseling
Legal services
Rape
Stalking

Other Languages Spoken
French
Spanish
Other:

Ages / Groups
All ages
Adolescents / Teens
Adults
Children
Couples
Family
Men
Women

Payment options
Fee for service
Insurance
Sliding scale fee
Other

 

 

Additional Information/Comments:
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