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Employee Information

First Name

Last Name

Date of Birth

Preferred First Name

Gender

Pronouns

Who are you?

If you are family, covered employee’s name

Agency/Organization where covered employee works

Have you used EAP before?

If yes, under what name (if different)?

Home Street Address

City/Town

State

Zip Code

OK to send you mail?

Personal Email

Ok to send you email?

Job title of the covered employee

I give the EAP permission to email me a short survey about my experience

Contact Information

Preferred Phone

(P) Phone Type

(P) Ok to leave voicemail?

(P) Ok to text?

Alternative Phone

Invalid value

(A) Phone Type

(A) Ok to leave voicemail?

(A) Ok to text?

Emergency Contact Name

Relation to you

Emergency Contact Phone

Invalid value

Demographics

Job type

Length of Service (years)

Sexual Orientation

Do you identify as transgender?

Racial/Ethnic Identity

How did you hear about EAP?

Marital/Relationship Status

Health Insurance Carrier

Military Service?

If yes, which branch?

Union Member?

If yes, which union?

Reason for contacting EAP

Did HR or a Manager/Supervisor suggest you contact EAP?

If so, was it a formal referral?

Are you having job performance or other job-related issues?

If yes, briefly explain:

What brings you to the EAP? What do you hope to get from your time at EAP?

Anything else you want us to know about you so we can best support you?

Over the past 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things

2. Feeling down, depressed or hopeless

Work Impact

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

Notice of Privacy Practices for the Washington State EAP

For Client Confidential Information

By law, we are required to notify you of your privacy rights, protect your personal health information, notify you if there is a breach under applicable law, and abide by the terms of this notice. This notice does not affect your care or eligibility for the Washington State Employee Assistance Program (EAP) Services.

What confidential information does the EAP have about me?
EAP creates a record of your contact, which includes demographic information, documentation of counseling sessions and EAP assessment, and other health information. Your participation in the employee assistance program and all individually identifiable information gathered in the process of conducting the program is held in strict confidence. (RCW 41.04.730)

Who sees my confidential information?
We keep only the minimum amount of confidential information needed to do our job. We may share information if allowed by law or permitted by you.

May I see my information?
You have the right to request to review or receive a copy of your record. Your provider may charge you for copies of your records.

May I change my records?
If you believe the health information in your record is incorrect, you may send a written request for consideration that we amend or add new information. You may also request that we send the amendments to others who have received a copy of your record.

What if someone else needs my confidential information?
A signed Release of Information form, effective for ninety (90) days from the date you sign it, would allow your information to be shared. You may withdraw or change this permission in writing.

May confidential information be shared without my permission?
EAP may share confidential information under the following conditions:

Abuse and Neglect: we report suspected abuse or neglect of minors, elderly and developmentally disabled to the proper authorities.
Threats to Health or Safety: If we reasonably believe there is an imminent danger to the health or safety of the client or any other individual, we may be required to take protective actions. These actions may include notifying a potential victim, contacting the police, seeking hospitalization for the client, or contacting your emergency contact or others who can help provide protection.
Legal Process: We disclose requested information pursuant to a subpoena or court order or as required by law.
To Business Associates: Business Associates are entities that provide services on our behalf which requires that they create, receive, maintain or transmit your personal information.
To Government: when required for specifically identified government functions such as national security or to the Department of Health and Human Services to determine compliance with obligations to protect the privacy of your health information, or to the extent necessary to comply with laws relating to workers’ compensation or other similar programs.
Additionally, RCW 41.04.730 stipulates that if you are referred by agency management due poor job performance, we give agency management only the following information:

Whether or not the referred employee made an appointment;
The date and time the employee arrived and departed;
Whether the employee agreed to follow the advice of counselors; and
Whether further appointments were scheduled.

What if privacy practices change?
We reserve the right to change practices in this notice. This notice is posted on our website at eap.wa.gov.

Who do I contact if I have questions?
You may call the EAP at 1-877-313-4455.

How do I report a violation of my privacy rights?
You can file a complaint with the Washington State Employee Assistance Program by calling or in writing at 1222 State Ave NE, Suite 201, Olympia, WA 98504-7540, or contact the Federal Department of Health and Human Services (HHS) at www.hhs.gov/hipaa/filing-a-complaint.

Client Statement of Understanding

About EAP: You are choosing to receive services from the Washington State Employee Assistance Program (EAP). EAP services include problem assessment, brief problem-solving assistance, resources, and referrals for treatment or additional support. The EAP counselor will work with you to clarify problems, identify choices, and help you to develop an action plan within 1-3 sessions.

Fees: Your employer fully funds EAP services. There is no cost to you for any services provided by EAP. EAP is separate from your insurance benefit. The EAP does not cover the cost of services we may refer you to, but we attempt to refer you to providers covered by your insurance plan. It is your responsibility to verify that your insurance will cover the cost of counseling or other treatments.

About your EAP Provider: All EAP providers hold a master’s degree or higher in a counseling-related field. Additionally, our providers are certified or licensed by the Washington State Department of Health. EAP providers are generalists but can refer you to specialists based on their assessment of your needs. While you are not entering therapy or treatment during your EAP visits, you may request and review a Counselor Disclosure Statement that will provide more information about your specific provider. Should you choose to continue seeing the provider after EAP sessions are complete, they must offer you alternative referrals and must provide a Counselor Disclosure Statement to you.

Confidentiality: EAP will maintain confidential records of your contact with EAP, including the information you share with us and the services provided to you. We need to have your written consent in order to share information about your care with another individual or entity. Exceptions to confidentiality are listed in detail in the Notice of Privacy Practices.

Does EAP tell my employer about my use of EAP?: RCW 41.04.730 states that “an individual employees' participation in the employee assistance program and all individually identifiable information gathered in the process of conducting the program shall be held in strict confidence; except that agency management may be provided with the following information about employees referred by that agency management due to poor job performance:

Whether or not the referred employee made an appointment;
The date and time the employee arrived and departed;
Whether the employee agreed to follow the advice of counselors; and
Whether further appointments were scheduled.”

Your Rights: As an EAP client, your rights include but are not limited to the following. You have the right:

to be treated with respect and dignity, and to receive EAP services without discrimination based on race, color, religion, national origin, language, sex, age, disability, sexual orientation, gender identity, gender expression, or veteran status;
to receive appropriate, ethical care and to refuse or terminate services at any time;
to ask questions about anything that happens during EAP services; and
to request a different counselor than the one assigned to you for the remainder of your EAP sessions.
Additionally, RCW 41.04.730 states: “Participation or nonparticipation by any employee in the employee assistance program shall not be a factor in any decision affecting an employee's job security, promotional opportunities, corrective or disciplinary action, or other employment rights.”

By signing below, I acknowledge that I understand the information provided to me on this form, including the confidentiality of the EAP and the limitations to confidentiality. I accept it as the terms of my participation in the program. With my signature, I also acknowledge that I received written information describing EAP’s Privacy Practices.

Consent Full Name*

Sign Here Using Mouse or Finger/Stylus Use Keyboard

Client Intake Form

Please Note: Providing demographic information is optional, but helps us to better serve you.

Notice of Privacy Practices for the Washington State EAP

Client Statement of Understanding