Village EAP for Affiliates

Man sitting in counseling session

The Village Employee Assistance Program's network of affiliates consists of professional counselors who have a minimum of Master's level education, who are licensed in their state of practice, and who carry adequate professional liability insurance. Proof of adequate education, licensure, and insurance is required before any client can be referred to an affiliate provider, and the required documentation is checked prior to any referral.

The Village Employee Assistance Program requires the completion of a minimal set of paperwork connected with affiliate providers submitting requests for reimbursement for services provided. For your convenience as a provider, we have made the relevant forms available on this webpage.

For more information about becoming an affiliate provider, contact us online or call The Village Employee Assistance Program at 1-800-627-8220.


Counselors providing services for The Village's Employee Assistance Program are required to complete referral packets for each new client. Required forms are listed below. Completed forms must be returned to The Village by providers to establish eligibility for reimbursement.

Instructions for Referral

Please choose the appropriate referral packet based on whether the client is new/inactive or is continuing services with The Village EAP.


Acknowledgement Statement

Please review this statement with Village EAP clients, providing any additional assistance required for clients to review and understand the document. Indicate that you have reviewed this document with the client on the billing form.

Billing Form

You may use this online form when billing for services provided to a client of The Village Employee Assistance Program. 

Eighth Session Review

Request additional sessions for a client via this online form

If you have any issues submitting these forms, please call The Village EAP at 1-800-627-8220 or contact us online.