Healthcare Employee Assistance Program Sign

HEALTHCARE EMPLOYEE ASSISTANCE PROGRAM CONSENT & INTAKE

Employee Information

Employee Name:

Date of Birth:   Gender: Male Female Other

Department:   Supervisor:

Emergency Contact

Relationship:   Phone:

Insurance & Billing

Policy Number:   Group Number:

I consent to billing my insurance for EAP services when applicable: Yes I prefer self-pay / confidential billing arrangements

Medical & Behavioral Health History

Primary Care Physician:   Phone:

Presenting Concerns & Risk Screening

Within the past month, have you felt you might harm yourself or others? Yes No

Do you have concerns about substance use impacting work or safety? Yes No

Consent for Services and Confidentiality

I hereby request and consent to services from the Employee Assistance Program (EAP). I understand that EAP services may include assessment, counseling, brief intervention, referral to community resources, and case management. Services offered may be in person, by telephone, or via remote telehealth modalities as determined appropriate by the EAP provider.

I understand that communications between me and EAP providers are confidential and protected under applicable privacy laws and program policies. Confidentiality is limited in the following circumstances: (1) if there is a reasonable suspicion of abuse or neglect of a child, dependent adult, or elder; (2) if there is an imminent threat of harm to self or others; (3) when disclosure is required by court order or legal process; (4) when I authorize release of information in writing; or (5) when necessary to coordinate care with other health providers for my safety.

I understand that EAP may provide limited administrative information to my employer for program administration only (for example, confirmation of attendance or participation, or referral status). I authorize the following limited disclosure to my employer:

I authorize limited disclosure to my employer for administrative purposes (attendance, referral status).

I decline any disclosure of information to my employer beyond mandatory administrative notices.

Authorization to Release Information

I authorize the EAP to release information from my EAP record to the following person(s) or entity(ies) as necessary for coordination of care, billing, or administrative purposes:

Purpose of Disclosure:

This authorization expires on:   or upon termination of EAP services, whichever occurs first.

Acknowledgments & Notices

By signing below I acknowledge that I have been informed of the scope and limits of confidentiality, the voluntary nature of participation in EAP services, and my right to withdraw consent at any time except where records must be retained by law. I understand that refusal to consent will not affect my employment status but may affect the availability of certain employer-sponsored support services.

I understand that records of EAP services are retained in accordance with applicable law and program policy and may be disclosed as required by law.

I acknowledge receipt of the program's privacy notice and understand my rights regarding access to my records, complaints about privacy practices, and corrections to my record.
I acknowledge receipt of the EAP privacy notice and related program policies.

Voluntary Consent & Signature

I have read and understand the information above. I consent to assessment and provision of EAP services consistent with this document. I understand I may revoke this consent in writing at any time, except to the extent that action has already been taken in reliance on this consent.

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