Welcome Information and Intake Form

Thank you for contacting our program for services. This form is to be completed by the person 18 years or older, who is scheduled for an appointment with our program. If the person scheduled is under 18 years old, this form must be completed and signed by the parent or legal guardian of the minor.

Please complete, sign and submit the form below prior to your scheduled appointment. If you have any questions or concerns, please reach out to C&FS EAP at 716-681-4300. This form may not be reviewed for up to 2 business days. If this is an emergency, please contact emergency services by dialing 911. If you are seeking mental health support and would like to speak to a counselor immediately, please call 716-681-4300 and press option 2, C&FS EAP is available.

You may review C&FS information and HIPAA Policy here.

"*" indicates required fields

Name*

Name of person scheduled for services with our program.

First Last

Race*

Please provide this information for the purpose of understanding our service users better. We will use this de-identified data to modify options and reflect the community to improve services.

Preferred Name

Please let us know how you would like us to refer to you while providing services.

Preferred Language

We are able to accommodate providing services in multiple languages. If needed, please let us know if you are requesting interpretation services and your preferred language. This will allow us to plan and serve you to the best of our abilities.

Email*

Please provide an email that we can use to communicate with you.

Email Permissions*

I give permission to send unencrypted emails for appointment reminders only and encrypted emails for all other private communications.

Phone*

Please provide the best phone number for us to reach you.

Text permissions*

I give permission to send unencrypted text messages for appointment reminders only.

Call and Message permissions*

I give permission to call this number when needed and to leave a message on voicemail. *

Emergency Contact*

Please identify a person we may contact in the event of an emergency. Please share the name, phone number and the nature of your relationship.

DOB*

Date of Birth

Organization or Association*

Tell us the name of the organization you or your household member is affiliated where you receive the benefits of our program.

Referral*

How did you hear about our program?

Best hope*

What would you like to accomplish by meeting with a counselor?

Concerns*

Please check all that apply and explain below:

I am concerned about my substance use/abuse.

I am concerned about my mental health.

I am concerned about losing my job.

I am concerned about someone else in my life.

I have a different concern.

Explain*

Please explain any concerns you checked above. *

Workplace Outcome 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.

Consent*

* 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.
** By signing below, I consent to services and acknowledge understanding the above information.**

** By signing below, I consent to services and acknowledge understanding the above information.**

Type Full Name of Person Signing*

Type Full Name

Relationship with person seeking services*

Relationship