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Intake

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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.

Client Information

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Invalid Home Address

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Please enter the Best Phone Number to Reach You

Please make a phone number selection

Invalid Email Address

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Invalid Birth Date

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Invalid Last 4 digits of Social Security Number

If you are not the employee with EAP benefit:

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Background Information

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Invalid Employer

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Please enter your Type of Medical Insurance

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What Brings You In?

Please describe your reason for contacting us

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

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

Please let us know how serious this problem is for you

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Please enter more details about the problem(s)

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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. 

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

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

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

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

Invalid Client Signature

 

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

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Invalid Relationship to client