Family Advocacy Outreach Network
Participating Agency Application

Fee Structure

Insurance Accepted

Mode of Therapy

Population Chiefly Served

Relevant Experience

If not included in the agency's literature, please describe the agency's experience working with reunifications, victims of sexual abuse or exploitation, domestic violence, and other forms of family trauma.

Insurance

Professional Liability Insurance ( minimum $3M/$1M). Send declarations page of current policy indicating limits and dates of coverage.

Has there ever been disciplinary action against the agency or any of the professionals in the Group (including, but not limited to, repreimand, suspension or revocation of license)?

Is the agency or any professional in the Group now the subject of any investigation or disciplinary action including, but not limited to, reprimand, suspension or revocation of licenst)?

Have you or the agency ever been a defendant in any lawsuit where claims were asserted against you or the agency for malpractice, breach of duty, or any other action related to your or the agency’s professional practice and where judgment was rendered against you or the agency?

Are you or the agency presently a defendant in a lawsuit where claims are asserted against you or the agency for malpractice, breach of duty or any other action related to its professional practice?

On our own behalf as individual Professionals and on behalf of the Group:

We hereby certify that the information provided on this application is true and accurate to the best of our knowledge and belief. We authorize NCMEC to inquire into the accuracy of any statements made on this application.

We agree to be bound by the ethical standards of our professional associations (either the National Association of Social Workers, the American Psychological Association, American Counseling Association or American Association for Marriage and Family Therapy).

We have read and understand the Requirements and Procedures of NCMEC’s Family Advocacy Outreach Network and agree to abide by them.

We agree to indemnify and hold harmless the Family Advocacy Outreach Network and NCMEC (including its officers, directors, agents, and employees) against any and all claims for loss, damages, or costs that arise out of any referrals of clients/patients and/or treatment of clients/patients so referred.

   I have read and agree to the terms and conditions above.