LifeCoaching - Provider Applications

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Welcome Providers!

This page provides the information and forms you will need to apply to our LifeCoach Network. Service in our network requires a minimum of a graduate degree in a helping profession (Counseling, Social Work, Psychology, etc. ) and the ICF's ACC-level coach certification or the CCE's Board Certified Coach credential. If you meet these qualifications and are interested in serving in our network on a fee--for-service, contractual basis please complete the green and blue forms on this page. Coaches who are also licensed therapists are also encouraged to apply by completing the same forms.

Application Directions

1. Complete and submit the green and blue forms on this page.

2. Fax copy of liability insurance (and license if also applying as therapist) to secure fax at: 616-825-6408, or email to network-manager@lifeoptions.com.

Join Our Practice Hub Community

Once you complete the network application and W-9 form on this page please feel free to become a member of our Practice Hub community of counselors and coaches. Registration is simple, easy and free, just click here to get started: practitioners.lifeoptions.com/web/practitioners-community/home . If you need help on this site please contact us via our help desk at www.practitioners.lifeoptions.com/web/practitioners-community/support.

Lyle Labardee, LPC; CEO of LifeOptions Group, Inc.

Web Form

LifeCoach Network Application

Please complete this form to submit an application to serve in the LifeCoach Network. All providers must have a minimum of a masters degree in a helping profession (Counseling, Psychology, Social Work, etc. ) and must be professionally credentialed through the CCE as a Board Certified Coach or through the ICF at the ACC level. Coaches who also intend to qualify as behavioral heath care providers must also be licensed and/or certified to practice independently.

First Name

Last Name

Home Street Address 1

Home Street Address 2

Home City

Home State

Home ZIp

Mailing Address

Home Phone

Cell Phone

Email Address

Practice Name

Practice Street Address 1

Practice Street Address 2

Practice City

Practice State

Practice ZIp

Date of Birth

Graduate Degree

Graduate Degree Institution

Coach Training Institution

ICF Coach Training Hours

ICF Coach Certification

Other Coach Training Hours

I have access to the internet, and a private and secure fax

I have professional liability insurance of at least $1M/$1M

I have never incurred a malpractice claim.

I have never been denied professional liability insurance or had my insurance cancelled

I do not have a current impairment to practice due to a mental, physical, or chemical dependency condition

I am currently free of any illegal drug use

I have never been convicted of our plead guilty to a felony crime?

Ethnicity (Optional: For member requests)

Professional Practice License - Type (leave blank if N/A)

Professional Practice License - Number (leave blank if N/A)

National Provider Identifier (NPI) # (leave blank if N/A)

Professional Practice License - State (leave blank if N/A)

I am a licensed behavioral health provider and I have held a professional practice license for at least 2 years.

I am a licensed behavioral health provider and my professional license or certificate has never been revoked,suspended, limited or voluntarily surrendered.

I attest that the above information is true and accurate and that any information that is subsequently found to be false may invalidate any agreements I may enter into or currently have with LifeOptions Services. Agree Disagree

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Web Form

LifeCoach Network W-9 Form

LifeCoach Network Provider applicants must complete this Substitute Form W-9. We are required by law to obtain this information from you when making a reportable payment to you. If you do not provide us with this information, your payments may be subject to 31% federal income tax backup withholding. Also, if you do not provide us with this information, you may be subject to a $50 penalty imposed by the Internal Revenue Service under Section 6723 of the Internal Revenue Code. This information must be consistent with the data provided on the Secure LIfeOptions Network Provider Application and on file with the IRS and the Social Security Administration.

Taxpayer Name

Taxpayer Street Address 1

Taxpayer Street Address 2

Taxpayer City, State and Zip

Taxpayer Identification Number or Social Security No.

Taxpayer Identification Type

Effective Date of Taxpayer Name and TIN

Name of Person Completing Form

Date Form Completed

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