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Please tell us about yourself

Company Name:

Client Type:

Email:

Date of Birth:

First Name:

Last Name:

Legal Sex:

Gender Identity:

Preferred pronouns:

Age:

Phone Type:

Phone:

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Address:

City/Town:

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Zip/Postal Code:

If you would like to be seen in a city other than where you reside, please enter the Zip code here:

Marital Status:

Race/ Ethnicity:

What is your preferred session modality:

Do you have a counselor preference (i.e. Male/Female, Religion Based, LGBTQ+ etc.):

what is your preferred method of communication?

Background

Why you are seeking short-term counseling services?

When did this problem begin?

How did you hear about us?

Is there anything else you would like us to know?

Employment Status:

Emergency Contact Name:

Phone (background):

Relationship to you:

Assessment

Have you had mental health treatment before? If so, please describe:

How do you rate your current wellbeing?

In the past few weeks, have you wished you were dead or would go to sleep and not wake up?

Are you thinking about harming or killing yourself right now? (If you answered Yes, call us at 1-800-969-6162 or go to your nearest emergency room):

Work Impact (Pre)

How many hours of work did you miss in the past 30 days?

My personal problems kept me from concentration on my work:

I am often eager to get to the worksite to start the day:

So far, my life seems to be going well:

I dread going into work:

EAP PARTICIPANT STATEMENT OF UNDERSTANDING

HelpNet Employee Assistance Program is pleased that you have chosen to use your EAP benefit. These services are offered to employees of contracted companies and their household family members, and may include assessment, brief counseling, and/or a referral by Master’s level counselors in social work, psychology, counseling, or other related fields.

EAP counseling is voluntary. Your employer has paid for their employees with personal and/or work problems to meet with a counselor for a limited number of sessions. We provide counseling for a variety of issues that affect mental and emotional well-being, such as work-life balance, alcohol and other substance abuse, stress, grief, family problems, and psychological disorders. If we are unable to help you with your counseling needs, your therapist may refer you to a community resource or treatment agency. In some cases, our EAP Counselors may be able to provide longer-term outpatient services using your health insurance or private pay option. If we refer you somewhere else, we will also give you other referrals to choose from, based on your preferences, insurance, and your ability to pay for continued treatment.

Confidentiality is very important to us. You are protected by the Health Insurance and Portability Act (HIPAA), which requires us to keep your health information confidential. We follow all state and federal requirements. We maintain secure written and/or electronic records of your contact with us and we will not share this information with anyone outside of our EAP staff without your written permission, except under the following situations in which we are required to report by law to the proper agencies:

Court order, or subpoena
Client may cause serious harm to self or others
Abuse or neglect of child, elderly or disabled adult, and/or
Serious emergency medical issues requiring immediate medical care

Federal law states we cannot disclose any drug/alcohol use or HIV/AIDS information, unless:

The employee consents in writing
The disclosure is allowed by a court order, or
The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

Medical/Clinical records are confidential clinical documentation by HelpNet Counselors. You have the right to request a copy of your medical record with signed written authorization. You must obtain documents from outside agencies from the original source. We will not release third party documents provided to HelpNet from outside agencies.

If you are here for family, couples, or any mode of therapy involving multiple individuals, all individuals who participated in counseling with you must sign a written release of authorization to release only the parts of the record relevant to the person on the release.

Minors of 14 years of age or older may request and receive mental health services without the consent or knowledge of their parent, guardian, or person in loco parentis unless the therapist determines it is necessary because of significant probability of harm to the minor or someone else, according to the Michigan Mental Health Code. State requirements allow services to be provided to a minor up to 12 sessions, or 4 months.

Management referrals occur when your supervisor/manager refer an employee for a work performance issue. If participating in the management referral program, your counselor may be required to disclose your compliance with treatment recommendations with your authorized employer representative, including alcohol or drug policy violations. Any of these disclosures will require your written authorization.

No-shows and late cancellations, less than 24 hours of your appointment, could result in an inability to schedule you for future appointments for individuals who do this on more than one occasion. In that event, we will be happy to provide referral information for other appropriate resources in the community. If you need to cancel an appointment and it is after our regular office hours, you may call us at any of the numbers listed below and leave a message with our answering service.

Quality service is important to us. If, at any time, during your participation with the EAP you have concerns about your counseling services, you are encouraged to discuss it with your therapist. If you are unable to reach your therapist or have spoken to your therapist and still dissatisfied, you are encouraged to contact HelpNet’s Manager of Business Operations at (269)245-3928.

I read and understand this Statement of Understanding.

I received my Recipient Rights and Notice of Privacy Practices.

I consent to assessment and treatment for mental health and/or substance abuse issues.

I give HelpNet permission to follow-up with me regarding how I am doing, and my satisfaction with services.

Client Full Name*

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Client Intake

Online Request Form for Counseling Services