Client Intake Form (TEST) Page 1 of 5 There was a problem submitting your form. Please review and ensure all required fields are completed. (*) I have reviewed the information in Employee Assistance of the Pacific’s Client Information and Notice of Privacy Practices. 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 Client's First and Last Name:(*) Invalid Client Name Name you prefer to be called: Invalid Input Home Address:(*) Invalid Home Address City:(*) Invalid City Zip Code:(*) Invalid Zip Code Best Phone Number to Reach You:(*) Please enter the Best Phone Number to Reach You (*) Okay to call me, leave a message, identify who you arePlease don’t call Please make a phone number selection Email Address:(*) Invalid Email Address May we email you? YesNo Invalid May we email you? Birth Date:(*) Invalid Birth Date Gender: MaleFemaleOther Invalid Input Last 4 digits of Social Security Number: Invalid Last 4 digits of Social Security Number If you are not the employee with EAP benefit: Employee Name: Invalid Input Employee Company: Invalid Input Relationship to You: Invalid Input Next Page > Background Information What is your current employment status? Full-TimePart-TimeSuspendedOn Leave, DisabledOther Invalid Input Employer:(*) Invalid Employer Job Title:(*) Invalid Job Title Job Level: ManagementProfessionalTrade/TechnicalSupport Invalid Input Altogether, how long have you been employed by your current company? Invalid Input Are you a Union Member? YesNo Invalid Input Name of Union: Invalid Input Education: Please check the highest level of education you have completed Elementary SchoolHigh School2-Year College Degree4-Year College DegreePostgraduate College DegreeOther Invalid Input Marital Status: SingleSeparatedMarriedDivorced/SingleCohabitating (living with partner) Invalid Input How long have you been with your current partner? Invalid Input Partner's Name: Invalid Input Partner's Age: Invalid Input Partner's Occupation Invalid Input Partner's Employer: Invalid Input Children - please list one per line and include the following details: Name Age Sex Living with you? Married? Invalid Input Others living with you - please list one per line and include the following details: Name Age Sex Relationship Invalid Input Ethnic Identity: Invalid Input Religious Affiliation or other Spiritual activities: Invalid Input Type of Medical Insurance? HMSAUHAKaiserOther Please enter your Type of Medical Insurance Other Medical Insurance Invalid Input < Previous PageNext Page > What Brings You In? Briefly describe your reason for contacting us:(*) Please describe your reason for contacting us How long has this been a problem for you?(*) Please let us know how long has this been a problem for you What other ways have you tried to handle this problem? Invalid Input What would you like to accomplish by coming here?(*) Please let us know what would you like to accomplish by coming here Overall, how serious is this problem for you?(*) Not Very SeriousSomewhat SeriousVery Serious Please let us know how serious this problem is for you Do you have any of the following problems? (Please check all that apply) Sleeping too little or too muchChronic tiredness or low energy levelFeelings of inadequacy or loss of self-esteemDecreased productivity or effectiveness at school/work/homeDecreased attention, concentration or ability to think clearlyWithdrawing from friendsLoss of interest or enjoyment in pleasurable activitiesLoss of interest in sexual activitiesLess active or talkative than usualRestless or anxiousPessimistic attitude toward the future, brooding over past events or self-pityTearfulness or cryingRecurrent thoughts of death or suicideOther (please specify): Invalid Input Details:(*) Please enter more details about the problem(s) Have you ever seriously contemplated or attempted suicide at any time in the past? YesNo Invalid Input If yes, please explain: Invalid Input What counseling or treatment have you had? (please check all that apply) PsychiatristPsychologistSocial WorkerSelf-Help GroupChurch CounselorAny other Counselor or Program (please specify): Invalid Input List Medications: (Prescription and Over the Counter) Reasons Taken Dose/Frequency Invalid Input How did you learn about the Employee Assistance Program? (check all that apply) Home MailingPosters/Flyers/PamphletsSeminar/TrainingFamily MemberOther EmployeeDoctorHR/PersonnelManagerUnionOther Invalid Input Who is primarily responsible for you coming to the EAP? (In other words, who got you to come in?) MyselfOther EmployeeSupervisor/ManagementHuman ResourcesFamily MemberOther Invalid Input < Previous PageNext Page > 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. 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. (If none type in the number 0, don't type in 'none')(*) 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(*) Strongly DisagreeSomewhat DisagreeNeutralSomewhat AgreeStrongly Agree 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(*) Strongly DisagreeSomewhat DisagreeNeutralSomewhat AgreeStrongly Agree 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(*) Strongly DisagreeSomewhat DisagreeNeutralSomewhat AgreeStrongly Agree You need to fill out the field: So Far, My Life Seems to be Going Very Well I Dread Going to Work(*) Strongly DisagreeSomewhat DisagreeNeutralSomewhat AgreeStrongly Agree You need to fill out the field: I Dread Going to Work < Previous PageNext Page > Client Signature(*) Invalid Client Signature If client is under the age of 18, Parent or Authorized Representative Signature is also required: Parent or Authorized Representative Signature: Invalid Input Relationship to client: Invalid Relationship to client < PrevSubmit If you have troubles completing this online form, please download the form and either email it to or fax it to (808) 597-8230.