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Caller Information

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Do you prefer counseling services near your home?

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If yes, please name your current provider

Client Information (If different from above)

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Assessment

Briefly describe your reason for seeking assistance

Impact on job performance

Have you been placed on a written warning or performance improvement plan?

Is counseling court ordered?

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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 an EAP Coordinator for any reason, including the department’s concern about your use of alcohol and drugs, EAP may disclose:

whether you have kept mandatory appointments;
whether you are compliant with EAP recommendations and other treatment recommendations.

EAP will not disclose other confidential information unless it falls within exceptions 1 - 6 above or you give your written permission to EAP to disclose it. If you believe that you have a medical condition that requires a reasonable accommodation, or if you wish to report discrimination or retaliation in the workplace, EAP will not disclose these facts unless you give EAP written permission to do so.

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*

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