Healthcare EAP Document

HEALTHCARE EAP DOCUMENT

Client Information

Date of Birth:    Gender:

Emergency Contact

Employer / Referral Information

Referral Source: Self Human Resources Manager Clinician/Provider Other

Insurance / Coverage (if applicable)

Presenting Concerns & Clinical History

Risk Assessment

Please indicate current/ recent concerns: Suicidal ideation or intent Homicidal ideation or intent Self-injurious behavior Substance misuse affecting functioning

Consent for EAP Services

I consent to receive Employee Assistance Program (EAP) assessment and short-term counseling services. I understand services are voluntary, confidential to the extent permitted by law, and intended to address work-related and personal concerns. I acknowledge that EAP services are not a substitute for long-term therapy when indicated and that I may be referred to community providers when clinically appropriate.

I understand the limits of confidentiality include mandatory reporting of suspected child or elder abuse, imminent risk of harm to self or others, and responses to lawful court orders or subpoenas. In such circumstances, information may be disclosed without my additional consent to protect safety or comply with legal requirements.

I authorize the EAP clinician to provide brief, factual information about my participation and attendance to my employer or designated representative if necessary for administrative or safety reasons. I understand that except for the limited information above, detailed clinical records will not be released to my employer without my signed authorization.

By checking the box below I acknowledge and give informed consent for EAP services under the terms described: I consent to EAP assessment and brief counseling

Authorization to Release Information (Optional)

I hereby authorize the release of information as indicated below to the person(s) or entity(ies) named. I understand that I may revoke this authorization at any time in writing, except to the extent that action has already been taken based on this authorization.

Release to Employer / Designated Representative: Authorize limited release to employer

HIPAA / Privacy Acknowledgment

I acknowledge that I have been provided with information regarding privacy practices and the handling of protected health information. I understand how my information will be used and that I may request restrictions or further information in writing. I understand that EAP records are maintained separately from my employer's personnel files.

Acknowledgment: I acknowledge receipt of privacy practices and consent to use my protected health information as described above

Emergency & Crisis Procedures

In the event of an emergency or imminent risk, I understand that the clinician will take appropriate actions, which may include contacting emergency services, notifying designated contacts, or arranging immediate evaluation. For life-threatening emergencies, I understand I should seek immediate help from emergency services.

Financial & Administrative Notes

EAP services are provided as a benefit of employment and are generally offered at no direct charge to the client for a limited number of sessions. If referral to external services is made, those services may be subject to separate fees and billing; I will be informed prior to any referral.

Client Certification

By signing below I certify that the information I have provided is true and accurate to the best of my knowledge. I have read and understand the terms of consent, confidentiality, limits to confidentiality, and authorization provisions above. I understand I may withdraw any authorization in writing, except as to actions already taken relying on this consent.

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