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Employee Information

Company/Organization providing benefit

Employee Name

Employment Status

How did you hear about EAP?

Employee occupation?

Employee years at company?

Information on person (Client) seeking services

Who are you?

Client First Name

Client Last Name

Birth Gender

Identified Gender

Date of Birth

Client Email

May we communicate via Email?

Marital Status

# of Dependents

Address

City

State

Zip

Client Primary Phone Type

Client Primary Phone #

May we call/leave message/text?

Emergency Contact Name

EC - Relationship to Client

EC - Phone Number

If there will be additional family members involved in this counseling, please list them here:

Counseling Information

Preferred Counseling Format

Preferred Gender of Counselor

Please choose your reason for seeking counseling

Please briefly explain

Have these issues been addressed in any prior counseling?

If yes, please explain

What do you expect/hope to gain from counseling?

Is counseling or treatment being provided by someone else/another provider at this time?

If yes, please indicate the type of provider you see

Are there any medications being used to treat the counseling issues?

If yes, please list the medications

Are you or those close to you concerned about your use of

Pre GAD-7

Are your counseling issues related to worry, fears or possible anxiety?

Generalized Anxiety Disorder (GAD-7) - Over the last 2 weeks, how often have you been bothered by any of the following problems?

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it's hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen

Pre PHQ-9

Are your counseling issues related to discouragement, sadness or possible depression?

Patient Health Questionnaire (PHQ-9) - Over the last 2 weeks, how often have you been bothered by any of the following problems?

If you selected any problems above, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Little interest or pleasure in doing things?

Feeling down, depressed, or hopeless?

Trouble falling or staying asleep, or sleeping too much?

Feeling tired or having little energy?

Poor appetite or overeating?

Feeling bad about yourself - or that you are a failure or have let yourself or your family down?

Trouble concentrating on things, such as reading the newspaper or watching television?

Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?

Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?

Work Impact (Pre-Workplace Five Item 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

Submit

STATEMENT OF UNDERSTANDING

Welcome to the Best Care Employee Assistance Program. We provide assessment, short-term counseling, and referral services to employees and eligible family members of our customer companies and organizations. These EAP services are provided at no cost to the employee or family member. It is the responsibility of the client to pay for any services outside of the EAP counseling benefit.

Services can be accessed in several ways. You may meet with a counselor in one of our Best Care EAP offices or you may meet with one of our contracted affiliate providers. You may also access our services via electronic means such as telephone, online chat or video (telehealth counseling). Telehealth counseling options are subject to the limitations of internet security. All Best Care EAP and affiliate counselors are licensed in their state of practice. Telehealth counseling is provided pursuant to the laws and regulations of each state.

Telehealth Statement of Understanding: Client understands that they are voluntarily participating in a telehealth visit and can discontinue the telehealth visit at any time, without affecting client’s right to future care or treatment. Client is aware that the telehealth appointment will be reviewing and discussing Client’s mental health history and present concerns. Information obtained will not be shared without the Client’s advance written consent. Client understands that the EAP counseling received via the telehealth visit will be the same type of counseling they would receive from an onsite counselor. Documentation of this Telehealth EAP visit is a part of the client’s EAP counseling record and is available upon request. It is understood and agreed to by Client that no session will be held, and Counselor will unilaterally cease the session, if doing so could place either Client or others in danger. This includes, but is not limited to, operating a motor vehicle of any kind, or equipment deemed to be unsafe.

All EAP counseling services are strictly confidential and your counseling information cannot be disclosed without your permission. There are a few exceptions:

If you see one of our affiliate providers, it is necessary for Best Care EAP and your provider to exchange counseling and billing information.
Certain reports to authorities are required by law, such as suicidal intent or threats of imminent physical violence toward others.
Suspected abuse of children, the elderly, and incompetent or disabled persons must also be reported.

In order to achieve a successful counseling outcome, you are expected to be a full participant in the counseling process. This includes arriving at mutually agreed upon counseling goals and a plan to achieve those goals with your counselor. It also includes attending sessions as scheduled. Appointment changes with less than 24 hours notice and no shows will count as a session and be deducted from your allotted sessions. After completing your counseling with Best Care EAP, we will solicit your feedback on that experience as an essential part of our ongoing effort to provide excellent counseling services.

It is the policy of Best Care EAP to use its best efforts to avoid participation in adversarial actions against customer companies or organizations, or in any client legal actions, such as child custody suits, divorce proceedings or personal injury lawsuits. If you are considering such actions, or are involved in such actions, your EAP counselor can refer you to an independent counseling professional for services. Since these services are outside your EAP benefits, costs for those services would be your responsibility.

If you have any questions or concerns about your EAP counseling services, please contact Best Care EAP’s Clinical Services Manager, Terry Coleman, at (402) 354-8000 or (800) 801-4182. He will do his best to answer your questions or address your concerns. If you are not satisfied after speaking with Terry, please contact our Corporate Director, Jean Faber at the same number. You may also contact Jeff Prochazka, our Vice President, at Nebraska Methodist Health System, (402) 354-6078, or the Nebraska Department of Health and Human Services, Division of Public Health, Licensure Unit at (402) 471-2115, regarding your concerns.

By signing below, you acknowledge that you have read and understand this Statement of Understanding and you give your consent for Best Care EAP to provide counseling services for you and any of your minor children who participate in the counseling.

Best Care Employee Assistance Program Notice of Privacy Practices

Please click on the link below to review and read the Best Care EAP Privacy Notice.
www.bestcareeap.org/hipaa-privacy

By signing below, you acknowledge that you have received the Methodist Health System Notice of Privacy Practices. (Note: My signature doesn't indicate that I have read, understood or agree with the Notice, only that it has been provided to me.)

Consent Full Name*

Sign Here Using Mouse or Finger/Stylus Use Keyboard

Counseling Registration Form

Online Request Form for Counseling Services

If you are experiencing a suicidal crisis or are in extreme emotional distress, please call 988. If needed, call 911 or go to the nearest emergency room.

If you have questions or need assistance with completing a form, please call our office at (402) 354-8000 or (800) 801-4182 or complete the Contact Us page on our website and we will reach out to you.