Affiliates

In the event that you are currently a HelpNet Affiliate provider or are desiring to become one, the information that follows will be helpful.

HelpNet places tremendous value on our partnerships with our national affiliates. We recognize we would not be the success we are without the contributions of our affiliates. Thank you.

Affiliate Library of Forms

Should you so desire, the following Affiliate Forms can be downloaded for your use. Questions related to any of the forms should be directed to HelpNet's Business Service's Coordinator at (800) 969-6162.

Clinical Assessment Form

Client Release Authorization

Client Statistical Data Form

Affiliate Packet Forms

Completed forms can be returned to HelpNet by one of three ways:

email:  bonneym@trinity-health.org  (Marcy Bonney)

fax: (269) 660-3890

mail: 36 W. Manchester, Battle Creek, MI 49037, attn: Marcy Bonney

Becoming An Affiliate

A HelpNet Affiliate must have a minimum of a Master's degree in a human services related field, be licensed and/or certified in the state in which he or she practices, and have three (3) years post-Master's degree experience in clinical work.

You may obtain a HelpNet Affiliate Application packet by either,

1. Calling HelpNet at (800) 969-6162 and asking to speak with the Business Services's Coordinator, or,
2. Downloading the following application forms, completing them, and returning them to HelpNet, 36 W. Manchester, Battle Creek, MI 49037 Attn: Provider Relations Coordinator.

Survey of Treatment Providers

Affiliate Information & Procedures (information only, no need to return)

Should you prefer, the above forms can be faxed, (269) 660-3890, or emailed to bonneym@trinity-health.org 

The Business Services's Coordinator will still need to send by mail the Affiliate Contract and the HIPAA agreement for review, signature, and return.