| To be completed by EAP Counselor -Billing Form |
|
|
|
|
|
|
| Affiliate
Name |
|
|
|
|
|
Telephone ______________________ |
|
| Address |
|
|
|
|
|
|
|
EIN or SS# ______________________ |
|
|
|
|
|
|
|
Client Name _____________________ |
|
|
|
|
|
|
|
Employer _______________________ |
|
|
|
|
|
|
|
|
|
|
| Assesed
Problems |
|
|
|
|
|
|
|
Emotional/ Psychological |
|
Relationship |
|
Abuse |
|
|
|
|
|
|
|
|
|
|
|
Job Related Stress |
|
|
Marital |
|
Sexual |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Legal |
|
|
Significant Other |
|
Physical |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Financial |
|
|
Parent/ Child |
|
Mental |
|
|
|
|
|
|
|
|
|
|
|
|
|
Medical |
|
|
Work |
|
Substance |
|
|
|
|
|
|
|
|
|
|
Work Performance |
|
|
|
|
|
|
|
|
|
|
| Activity |
|
|
|
|
|
Worksite |
|
|
Office Visit |
|
Cancelation |
|
No Show |
|
|
|
|
|
|
|
|
|
|
|
|
Resolution: |
|
Refferal: |
|
Accept |
|
|
|
|
|
|
|
|
|
|
|
|
Improved |
|
|
Hospitalization Inpatient |
|
Legal Consult |
|
Yes |
|
|
|
|
|
|
|
|
|
No Change |
|
|
Hospitalization Outpatient |
|
Financial |
|
No |
|
|
|
|
|
|
|
|
Continues to Receive Help |
|
Psychiatric Consultation |
|
Medical |
|
|
|
|
|
|
|
|
|
Outpatient Therapy |
|
Other |
|
|
|
|
|
|
|
|
Referral Name: |
|
|
|
|
|
|
|
City, State: |
|
|
|
|
|
|
|
Phone: |
|
|
|
|
|
|
|
|
|
IF SUPERVISOR REFERRAL: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Positive Drug Test |
|
Accident |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Absenteeism/Tardy |
|
Substance Abuse |
|
Date:
____________ |
|
|
|
|
|
|
|
|
|
|
Interpersonal Relat. |
|
Other |
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
|
|
|
|
| PLEASE NOTE:
IF THE CLIENT IS AT RISK, CONTACT SAI IMMEDIATELY FOLLOWING COUSELING
SESSION |
|
| |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Date |
Time |
|
Duration |
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
1930 Bishop
Lane |
|
| |
|
|
|
|
Watterson
Towers- Suite 1001 |
|
| |
|
|
|
|
Louisville,
KY 40218 |
|
| |
|
|
|
|
|
|
| |
|
|
|
|
Office Hours _________________ |
|
|
| |
|
|
|
|
Work-Site Hours ______________ |
|
| |
|
|
|
|
|
| I
certify that the above accurately represents the services I have provided
this month on behalf of Stuecker and Associates. |
|
|
| |
|
|
|
|
|
|
|
|
| Signed |
|
Date |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
