Client Intake Form (TEST)

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Invalid Acknowledgment

I understand this form, including the confidentiality in the EAP/PAP and the limitations to confidentiality, and accept it as the terms of my participation in the program. I understand that my participation is voluntary and that I can discuss any questions with my counselor during my first visit.

I also understand that I need to contact the EAP office between 8-5 Mondays through Fridays to set up an appointment for services.

Client Information

Invalid Client Name

Invalid Input

Invalid Home Address

Invalid City

Invalid Zip Code

Please enter the Best Phone Number to Reach You

Please make a phone number selection

Invalid Email Address

May we email you?
May we email you?

Invalid May we email you?

Invalid Birth Date

Gender:
Gender:
Invalid Input

Invalid Last 4 digits of Social Security Number

If you are not the employee with EAP benefit:

Invalid Input

Invalid Input

Invalid Input

Background Information

What is your current employment status?
What is your current employment status?
Invalid Input

Invalid Employer

Invalid Job Title

Job Level:
Job Level:
Invalid Input

Invalid Input

Are you a Union Member?
Are you a Union Member?
Invalid Input

Invalid Input

Education: Please check the highest level of education you have completed
Education: Please check the highest level of education you have completed

Invalid Input

Marital Status:
Marital Status:

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Type of Medical Insurance?
Type of Medical Insurance?

Please enter your Type of Medical Insurance

Invalid Input

What Brings You In?

Please describe your reason for contacting us

Please let us know how long has this been a problem for you

Invalid Input

Please let us know what would you like to accomplish by coming here

Overall, how serious is this problem for you?(*)
Overall, how serious is this problem for you?
Please let us know how serious this problem is for you

Do you have any of the following problems? (Please check all that apply)
Do you have any of the following problems? (Please check all that apply)

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Please enter more details about the problem(s)

Have you ever seriously contemplated or attempted suicide at any time in the past?
Have you ever seriously contemplated or attempted suicide at any time in the past?
Invalid Input

Invalid Input

What counseling or treatment have you had? (please check all that apply)
What counseling or treatment have you had? (please check all that apply)
Invalid Input

Invalid Input

How did you learn about the Employee Assistance Program? (check all that apply)
How did you learn about the Employee Assistance Program? (check all that apply)
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Who is primarily responsible for you coming to the EAP? (In other words, who got you to come in?)
Who is primarily responsible for you coming to the EAP? (In other words, who got you to come in?)
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Five Final Questions

Below are a series of statements that refer to aspects of your work and life experience that may be affected by the personal problems you want to address at EAP during the past 30 days. Please read each item carefully and answer as accurately as you can.  Remember that your answers will not be shared with your employer.

Invalid Number of Work Hours Missed

Instructions:

The following statements reflect what you may do or feel on the job or at home.  Please indicate the degree to which you agree with each of the statements for the past 30 days. 

My Personal Problems Kept Me from Concentrating on My Work(*)
My Personal Problems Kept Me from Concentrating on My Work
You need to fill out the field: My Personal Problems Kept Me from Concentrating on My Work

I Am Often Eager to Get to the Work Site to Start the Day(*)
I Am Often Eager to Get to the Work Site to Start the Day
You need to fill out the field: I Am Often Eager to Get to the Work Site to Start the Day

So Far, My Life Seems to be Going Very Well(*)
So Far, My Life Seems to be Going Very Well
You need to fill out the field: So Far, My Life Seems to be Going Very Well

I Dread Going to Work(*)
I Dread Going to Work
You need to fill out the field: I Dread Going to Work

Sign Above
Invalid Client Signature

 

If client is under the age of 18, Parent or Authorized Representative Signature is also required:

Sign Above
Invalid Input

Invalid Relationship to client

If you have troubles completing this online form, please download the form and either email it to info@eapacific.com or fax it to (808) 597-8230.

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