Home Page

Signature is required

Caller Information

Who are you?

What can we do for you?

SSN

Please tell us a little more about yourself

Company/Institution Name

First Name

Last Name

Gender

Date of Birth

Phone Type

Phone

Invalid value

Extension

Address

City/Town

State/Province

ZIP/Postal Code

Marital Status

Demographics

How did you hear about EAP

Referred By

Department

Job Shift

Location

Assessment

Which of the following areas do you wish to most improve on?

Alcohol

Exercise

Nutrition

Smoking

Social

Stress

Weight Management

How do you take care of yourself Physically?

How do you take care of yourself emotionally

How do you take care of yourself socially

How do you rate your overall wellbeing?

Work Impact (Pre Workplace Five Item Survey)

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

My personal problems kept me from concentrating on my work

I am often eager to get to the work site to start the day

So far, my life seems to be going very well

I dread going into work

Did you work any part of your normal employment schedule in the past 30 days?

How would you rate your overall job performance on the days you worked during this timeframe? (0 is the worst job performance possible and 10 is the performance of a top worker).

I am satisfied with the service I received.

I would recommend this service to others.

Submit

EAP STATEMENT OF UNDERSTANDING AND AGREEMENT ON CONFIDENTIALITY:
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 King County is 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:
1. whether you have kept mandatory appointments;
2. whether you are compliant with EAP recommendations and other treatment recommendations;
3. whether EAP recommends your return to duty; and
4. whether there are any known restrictions in the performance of your job.

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.

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

Counseling Services

Online Request Form for Counseling Services

If you are experiencing a life-threatening situation please call 911 or immediately go to an emergency room.

If you are experiencing suicidal thoughts, homicidal thoughts, or domestic violence, DO NOT complete this form. Please call OUR 24/7 toll-free number at 1(555)555-5555.

We request the following information as a quick and easy way to refer you to a professional. Our questions screen for your health and safety, which is our primary concern.