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Caller Information

Who are you?

What can we do for you?

How would you like to schedule your appointment?

NOTE: Better Help only provides COUNSELING they do not provide legal, financial, or other worklife Services

Type of Counseling?

Spouse or Dependent name

Spouse or Dependant Date of Birth

Please tell us a little more about yourself

Company/Institution Name

Personal Email

If CommonSpirit, which facility?

First Name

Last Name

Gender

Date of Birth

Primary Phone Type

Primary Phone

Can we leave a message at this phone #

Address

City/Town

State/Province

ZIP/Postal Code

Marital Status

Presenting Problem

Demographics

How did you hear about EAP

Referred By

Department

Years Employed

Education

Ethnicity

Performance Problem

Submit

Statement of Understanding

Profile Employee Assistance Program (“EAP”) offers assessment; short-term outcomes-based counseling & referral services to employees and their eligible family members (“Client”) of participating companies and/or organizations (“Employer”). Services provided within the EAP counseling benefit are provided at no direct cost to the Client. It is the responsibility of the Client to pay for any services outside the EAP counseling benefit. The duration of the counseling sessions depends on the Employer’s contract with EAP.

EAP provides a 24-hour crisis line to handle after-hour emergencies. The crisis line can be accessed by calling (719-634-1825) or (1-800-645-6571).

In some locations, EAP uses a web-based outcome counseling tool. At the beginning of each session, the Client will be asked to complete a brief questionnaire that will allow EAP to measure the Client’s success in counseling. This web-based tool is compliant with industry standard security practices.

Client Rights

Information the Client provides to EAP will not be released without Client’s prior knowledge and written consent except under the following circumstances: EAP counselors may be required to and will report threats of imminent physical violence or suicidal intent as well as suspicion of child/elder abuse or neglect, or if Client falls under the Department of Transportation (DOT) and presents a risk to public safety. Client’s EAP counselor may also consult or share clinical information with other Profile EAP counselors or with contracted (Profile EAP) counselors when necessary to assure quality clinical services.

Management Referrals are subject to different standards. A management referral is a request or requirement from Client’s Employer, supervisor or manager. Client will be asked to complete and sign additional forms if formally referred by Client’s Employer.

Upon request, Client is entitled to information about the methods of counseling, the techniques used, the duration of counseling, information regarding educational degrees, clinical training & experience, licenses & credentials of Client’s EAP counselor. When requested in writing, a treatment summary will be provided at Client’s expense. Client may terminate counseling at any time.

To file a complaint about EAP, Client may call the “Centura Integrity Helpline” at 1-888-424-2458 or go to www.integrityhelpline.org. If Client speaks a language other than English or Spanish or requires visual or hearing assistance to file a complaint, Client’s EAP counselor will contact the Colorado Department of Regulatory Agencies (DORA) to assist Client with Grievance Procedure.

Client Responsibilities

I understand that if I am unable to keep an appointment, I will call 24 hours in advance to cancel or reschedule my appointment. Failure to do so will be considered a “no show” and will be counted towards my EAP counseling benefit for that year. If I arrive more than 15 minutes late for an appointment, I understand that I may be asked to reschedule my appointment. Late arrival appointments which are rescheduled will not count as a session. Late arrivals may be offered a shortened counseling appointment depending on the counselor’s availability. Those appointments will count as a session.

I understand it is EAP’s policy not to participate in legal actions such as custody suits, divorce proceedings, personal injury suits, etc. If I am considering or are involved in such actions, my EAP counselor will direct me to contact a professional experienced in legal matters, at my own expense.

I understand that EAP will not complete FMLA paperwork, return-to-work paperwork, or disability paperwork but may work with my health care professional or established EAP Counselor, if needed.

I understand that my records may be transferred electronically. I understand that my participation in EAP counseling is voluntary and that all my records are protected by confidentiality regulations.

I have read this form and understand my rights and responsibilities as a Client. I hereby give my permission to have EAP follow-up upon completion of services to assess my satisfaction.

Telehealth Counseling and Electronic Medical Records (EMDR)

EAP uses “EAP Expert” as our EMDR. EAP does not use “EPIC” (EMDR for Centura) to schedule or document sessions. Both Centura Health and Profile EAP use Centura Health Virtual Care (CHVC) for Telehealth. For confidentiality, EAP uses a separate platform than Centura Health. Though platforms are separate, providers using CHVC will be able to view other providers and related medical services. Therefore, your EAP visit(s) will show up in your treating providers list in CHVC, treatment history section, as a “specialty provider” appointment with the name of the EAP counselor you saw. To further protect your confidentiality and minimize the information available to other providers using CHVC, EAP recommends not filling out the “reason for your visit” and not opting to share your visit summary. No other information will be available to your treating provider.

I have read and understand the above information. A Copy of this form is provided upon request.

Consent Full Name*

Sign Here Using Mouse or Finger/Stylus Use Keyboard

Counseling Services

Online Request Form for Counseling Services

DO NOT FILL OUT THIS FORM IF: you are experiencing a life-threatening situation, have suicidal thoughts have homicidal thoughts or in a Domestic Violence situation; Please call 911, or go to the nearest emergency room immediately.

Or call:

988 for the National Suicide Prevention & Crisis Lifeline

or

1-844-193-5255 for the Colorado Crisis Service Line or text “TALK” to 38255

Profile EAP offers 2 options for scheduling using this registration form :

This is a free, CONFIDENTIAL* service. None of the information below, your attendance, or any clinical notes will be released to your employer or anyone else without your written permission.

*By law we are required, and have a duty to report anyone who is a danger to themselves or others, involved in domestic abuse, child abuse or elder abuse to the proper authorities. Your rights as a client will be discussed by your counselor with you.