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Caller Information

Company Name

Your Company Division / Location (if applicable)

Employee ID (if applicable)

First Name

Last Name

Please tell us a little more about yourself

Home Street Address

City

State

Postal Code

Phone Type

Phone number to contact you

Does Concern have your permission email and/or text you?

Personal Email Address

Does Concern have your permission to email you?

What is your preferred method of communication?

Date of Birth

Your Gender

Work Impact

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

Additional Information

Client Status

Years of Service to Employer

Source of Referral

If you would like a referral at any location other than close to your home, please indicate a preferred zip code

Are you requesting Onsite Counseling (if offered by your employer)? If so, what locations (in order of preference)?

What type of counseling are you requesting?

Which of the following best describes your situation

Do you have a counselor gender preference?

Enter special requests below (i.e. language)

Submit

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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 King County is served with a subpoena compelling disclosure.
EAP may disclose confidential information if disclosure is reasonably necessary for YOUR Employer, its departments, divisions, agencies, and employees to defend against any charges or claims by the employee, related to the employee’s EAP counseling session(s).
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;
whether EAP recommends your return to duty; and
whether there are any known restrictions in the performance of your job.

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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