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Please tell us a little more about yourself

Company/Institution Name

First Name

Last Name

Gender

Date of Birth

Phone

Is there a restriction to leaving a voice message?

Marital Status

Address

City/Town

State/Province

ZIP/Postal Code

Primary Presenting Concern

Secondary Presenting Concern

Please tell us a little more about why you are requesting EAP services

Demographics

Are you an Employee or Household Member (primary residence is shared with employee)?

How long have you worked for your organization?

How did you hear abour EAP services?

Age Range

Region/Location of Work

WOS

For the period of the past 30 days, please total the number of hours your personal concern caused you to miss work. Include complete eight-hour days and partial days when you came in late or left early

My personal problems kept me from concentrating on my work

I am often eager to get to the work site to start the day

So far, my life seems to be going very well

I dread going into work

Submit

STATEMENT OF UNDERSTANDING:
We are pleased that you have decided to use your Employee Assistance Program. There are several things we want you to know before we begin discussing your reason for requesting services.

Life issues or problems are sometimes difficult to discuss.That is why confidentiality has to be as important for us as it is for you. We take every precaution to protect the confidentiality. We do not discuss your situation outside our offices or send records to anyone unless you give us written permission. There are four exceptions to that rule:

If we learn about child abuse or neglect, or abuse, neglect or exploitation of incapacitated adults, we are required by law to report it to the proper authorities.
If, in our judgment, an EAP client is dangerous to him or herself or others, we will disclose information to help protect a person from harm.
If we are required to present records or testimony to act in accordance with a court order it may be our legal responsibility to comply.
If your employer has required you to consult with and follow the recommendations of EAP, we will advise your employer whether you have done so. We will not disclose any further information without your written consent.

We want to provide a safe and comfortable place for you to discuss your concerns. We will listen, help you with an assessment and then develop a plan of action. The plan of action may include a referral to an appropriate source of help. For example, while EAP does not offer long- term outpatient counseling, court mandated counseling, or expert court testimony, should you need these services we can refer you to someone who does.

There is no cost to you for any services provided by Healthy Life EAP. The Employee Assistance Program, however, does not cover the costs of any referral services you may need. While we attempt to maintain up-to-date information on your health plan so we can refer to covered providers, it is your responsibility to verify your insurance coverage and to follow the procedures outlined in your policy. If you must cancel or postpone an appointment, we expect you to give us 24 hours’ notice.

This is a telehealth visit with the employee or household member located in their residence. Your provider informed you of the benefits and risks of telehealth, including the risk that personal information could be exposed during telehealth visits or that technical problems or the type of health problem being treated could result in the transmission of information that is not adequate for medical decision making. Your provider informed you that this visit will be documented in your confidential record. You understand you have the right to verify the identity of your telehealth provider. You understand that you have the right to stop or refuse services at any time and request the same service in a face-to-face setting. You verbalized consent for this visit.

By accepting below I acknowledge that I have read and understand the above statement and that I agree to proceed pursuant to the terms set forth above.

Consent Full Name*

Sign Here Using Mouse or Finger/Stylus Use Keyboard

Telecounseling Consent Form

Online Request Form for Telecounseling Support

If you are experiencing a life-threatening situation, please call 911 or go immediately to an emergency room.