EAP Service Request
Complete this form to request service from Ascension EAP, we'll contact you to help.
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Signature is required
To help best serve you, please tell us a little more about yourself.
Organization You Receive EAP Through
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Brief description of the issue this appointment is being requested for, or if you are not seeking an appointment, please let us know how we can help.
If this appointment you are requesting is for someone other than yourself, please let us know their information.
Relationship to you:
Please read and sign our statement of understanding.
EAP STATEMENT OF UNDERSTANDING AND AGREEMENT ON CONFIDENTIALITY:
Ascension WI EAP provides evaluation of personal problems, short term counseling, management consultation, referral and follow-up services. It is important that before you proceed with this process you understand the following limits.
All contact with Ascension WI EAP, is a private communication. Your appointment and the nature and content of your appointment can not be revealed to anyone, e.g., family members or employer. Exceptions must be made in the following circumstances:
A client can give permission to disclose through a signed release of information form. This form is your permission to release information to whomever you have designated. The release must be to a specific person or clinic, e.g., your supervisor or another therapist.
According to state law, all counselors are required to report suspected child abuse, child neglect or abuse of an adult who is not competent to conduct their own affairs. These reports are made to the appropriate county or state agency.
According to state law, if a client threatens suicide, a counselor must seek help for that person by reporting to family, police or other community resources. If a person threatens to physically harm another person, the counselor must report this to local authorities and to the intended victim.
The privilege of confidentiality for minors (under 18) is held by the parents, guardian or parent with custody. Information from a session may be shared with the holder of the privilege. Emancipated minors are an exception. Information about an emancipated minor may be shared with parents/or guardian if not to do so endangers that minor.
If you have concerns about what you can or cannot discuss in a session speak with your Employee Assistance Counselor. You may first want to discuss this in general terms and then the counselor can help you decide how this may or may not apply to your specific situation.
In some cases, a referral to another service or resource outside of the EAP may be offered to you. These referrals are suggestions: the decision to use or not to use these resources is at your discretion. The cost for these resources is outside of the EAP service and you will be responsible for any fees incurred.
I have read and understand the above statement and have been provided a copy of the Ascension WI EAP “Notice of Privacy Practices”.
Consent Full Name
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