Information on Employee providing the EAP / Insurance Benefit
Date of Birth: Social Security Number: XXX-XX-
Relationship to Client:
Company Name and Location:
Occupation: Years of Service:
Information on the Client
Date of Birth:
City, State, Zip:
Home Phone: OK to Call?
Other #: OK to Call?
Social Security Number: XXX-XX-
Primary Care Physician (Name, Address, Phone):
Insurance Company (Name, Policy Holder, Policy Number):
Please describe the concern/problem for which you are seeking assistance
List Household Members
Please select a response for each of the following categories:
Length of Employment:
less than 1 yr
Please indicate your Medication and Substance Use
If you have any past or present problems with medications, drugs or alcohol please explain:
Please describe any major health problems or allergies:
Please describe any past or current problems with abuse or mistreatment:
Please describe anything else you think would be helpful for me to know:
By checking this box and entering my name below I agree that all of the above is true.
This information has been disclosed to you from records protected by the Federal Confidentiality Rules (42 CFR Part 2). These Federal rules prohibit you from making any further disclosure of this information, unless further disclosure is expressly permitted by the patient or as otherwise permitted by the 42 CFR Oar 2. A general authorization for the release of is information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any drug or alcohol patient.