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Confidential EAP Intake Form

First Name

Last Name

Client First Name

Client Last Name

Address

City/Town

State/Province

ZIP/Postal Code

Phone Type

Phone Number (with area code)

Permission to leave message?

Gender

Preferred Email Address

Date of Birth

Parents Name (If client is under 18 years old)

Names(s) of Eligible Dependant Children, Age

If the appointment is for a minor child, please provide their name and age

What is the name of the company offering the Northstar EAP benefit?

Do you work for the company that offers the EAP benefit?

If no, please list the employee name that works for the company with the EAP benefit

How are you related to that employee?

Do you have a counselor preference?

What is your preferred counseling delivery method?

Is this a mandatory referral from your employer?

Health Insurance Information

Name of Insurance Carrier

Group#

ID#

If applicable, please list the name of any referring EAP group?

If applicable, please list the authorization number from the referring EAP?

Health Screening Questionnaire

Please select why you reached out to Northstar EAP

Your present state of health

Allergies?

If yes, Type(s)

Are you currently under the care of a physician?

If yes, what is the name of your physician?

Please list the medications you are currently on, dosages and what condition they treat

Any communicable diseases?

If yes, please indicate

Physical disabilities/limitations?

If yes, please indicate

Please list any past or present medical problems (i.e head injury, heart disease, diabetes)

Have you ever felt the need to bet more and more money?

Have you ever had to lie to people about how much you gamble?

Do you use/abuse drugs (legal/illegal)?

If yes, please specify

Have you ever felt you should cut down on your drinking?

Have people annoyed you by criticizing your drinking?

Have you ever felt bad or guilty about your drinking?

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

Over the past 2 weeks, how many days did you drink any alcoholic beverages?

Over the past 2 weeks, on the days you drank an alcoholic beverage, how many drinks did you have per day on average?

PHQ-9 - Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things?

Feeling down, depressed, or hopeless?

Trouble falling or staying asleep, or sleeping too much?

Feeling tired or having little energy?

Poor appetite or overeating?

Feeling bad about yourself - or that you are a failure or have let yourself or your family down?

Trouble concentrating on things, such as reading the newspaper or watching television?

Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?

Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?

GAD-7 - Over the last 2 weeks, how often have you been bothered by any of the following problems?

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it's hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen

Submit

EAP STATEMENT OF UNDERSTANDING AND AGREEMENT ON CONFIDENTIALITY AND CONSENT TO ELECTRONIC BASED SERVICES:
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 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.

All communication with Northstar EAP, including telephone, email, messaging, text and webcam platforms are considered private and confidential. Northstar follows all HIPPA regulations in order to safeguard your Protected Health Information (PHI). PHI will never be forwarded to a third party without your written request and agreement. The use of technology to assist in counseling makes it possible for clients to access expert care anytime, anywhere. However, clients must be aware of the risks. Please take steps to safeguard the information on your device; understand that it may be breached by those that have access to your device or passwords, and protect your privacy during therapist-client interactions.

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.

Cancellation Policy: By signing below, the client agrees to adhere to our cancellation policy by contacting us at least 24 hours in advance to reschedule or cancel their appointment. If a client fails to do so, the scheduled session will count toward clients' total allowable sessions assigned for the calendar year.

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*

Sign Here Using Mouse or Finger/Stylus Use Keyboard

Northstar Employee Assistance Program

Online Request for Services Form

If you are a returning client and it has been more than one year since your last appointment or your employer has changed, we request you complete the intake form below.

This form is required to be completed before clients can access counseling through their EAP benefit.