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Caller Information

What can we do for you?

Organization/Institution

First Name

Last Name

Preferred Name

Please tell us a little more about yourself

Gender

Date of Birth

Phone

Extension

Primary Address

City/Town

State/Province

ZIP/Postal Code

Relationship Status

How did you become aware of the program?

Permissions to Contact

Permission to Call

Permission to send unencrypted text messages for appointment reminders only

Permission to Leave message

Permission to send unencrypted emails for appointment reminders only

Permission to send encrypted emails for other communication

Assessment

What do you hope to achieve with sessions?

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

Submit

EAP STATEMENT OF UNDERSTANDING AND AGREEMENT ON CONFIDENTIALITY:
The services provided by your EAP may include: consultation, coaching, short-term counseling, information and/or referral services. All of these services are provided at no cost to you. If your situation requires further or more specialized services, a referral will be made to other resources within our agency or the community. It is important to note that any costs associated with additional services will be your responsibility. Your health insurance plan may cover some of the costs and the EAP staff will assist to the fullest extent possible.

Your Rights as a Client of Our Program
As a client of C&FS EAP, you are entitled and welcome to:

Inquire about the professional qualifications of C&FS EAP staff who will be providing services for you;
Inquire about and comment on agency/program policies and procedures;
Make suggestions as to how our services and/or procedures may be improved;
All personal information provided will be managed in accordance with HIPPA regulations, a copy of these regulations and agency/program’s Confidentiality Policy will be made available upon request.

Resolution of Concerns/Complaints:
C&FS EAP is dedicated to providing the highest quality services. If we do not meet the standard of care that was expected, we encourage you to reach out to any C&FS EAP staff member. The concern/complaint will be explored to the fullest extent possible and results of the process will be shared to the extent possible, while adhering to HIPAA requirements.

Cancellation/No-Show Policy:
In an effort to respect availability of appointments, we kindly request that you provide a minimum of 24 hours’ notice if you are unable to attend your scheduled session. This notice will allow for someone else to take advantage of this appointment slot. If cancellation notice is not provided within 24 hours, the scheduled session may be counted as one of your allowed sessions through EAP.

In the Event of Building Evacuation:
If for any reason there is an evacuation, the C&FS EAP staff will provide direction to safely exit the building. You may resume meeting at conclusion of evacuation if times allows, or reschedule as needed.

Notice of Privacy:
The Health Insurance and Probability Act of 1996 ('HIPAA') requires that we provide you with a copy of the Agency's Privacy Practices upon request, and that we make a good faith attempt to obtain your acknowledgment of the receipt.

Consent to Telehealth and In-person services:
Telehealth and in-person services allow the EAP counselor to consult, coach and educate in-person and using interactive audio, video or data communication. I have the right to confidentiality. Any information disclosed by me during the course of service is confidential under the guidelines of HIPAA, state requirements for mandated reporting, duty to warn and where there is a real and immediate threat of suicide.

Client Agreement:
I have reviewed and understand the above policies and give my consent for contact using preferences identified above. I also give my consent for EAP services, in person or telehealth. I will contact a C&FS EAP staff member if I have any questions regarding this agreement or confidentiality.

Consent Full Name*

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Online Request for Services Form

Please be aware, this form is not for emergency use. If you need an immediate response due to an emergency, please call 911.

If you are in need of immediate assistance from a mental health counselor, please call the main EAP number 716-681-4300 or 1-800-888-4162, choose 2 and you will be connected directly.