Online Request for EAP Services
If this is a life threatening emergency, please dial 911
* denotes required field
Signature is required
Please tell us a little more about yourself
Organization/Company/Association/ Institution Name that provides the EAP service
Date of birth
Primary Phone #
(P) Phone # type
(P) Permission to leave a message?
May we contact you via email regarding your service request
How can we assist you?
Additional detail (200 characters)
EAP STATEMENT OF UNDERSTANDING AND AGREEMENT ON CONFIDENTIALITY:
Information you provide to an Employee Assistance Program(EAP) Coordinator during a counseling session is confidential. EAP will not disclose the information without your written consent except as set forth below:
EAP may disclose confidential information if it concerns abuse or neglect of a child, dependent adult, or disabled person.
EAP may disclose confidential information if it concerns the infliction of bodily harm or the intent to inflict bodily harm on a person.
EAP may disclose confidential information if EAP determines that disclosure is reasonably necessary to prevent a direct threat to the health or safety of yourself or others during the performance of your job.
If your department has directed you to meet with EAP for any reason, including the department’s concern about your use of alcohol and drugs, and you have signed a written release EAP may disclose:
Dates of contact with EAP;
whether you have kept appointments;
whether you are compliant with EAP recommendations and other treatment recommendations; and
estimated time to complete the EAP treatment plan.
EAP will not disclose other confidential information unless it falls within exceptions 1 -4 above or you give your written permission to EAP to disclose it.
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