DEA EAP FORMS

Clinical-Counseling Only

Required Forms and Policy Information

• Form #1: Admission
• Form #2: Statement of Understanding (English)
• Form #2: Statement of Understanding (Spanish)
• Form #3:  Service Receipts - (need one signed for each session)
• Form #4:  Client Satisfaction Survey approval
• EAP Polices and Procedures for Clinical-Counseling
• Confidentiality Guidelines
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Special and Multi-Use Forms

• Form #3b: Area Clinicians only Service Receipt - multi-use (need one signed for each clinical, training. or briefing)
• Form #5: Authorization to Release Confidential Information
• Form #7: Threat of Violence
• Form #8: Clinician Self Referral Disclosure
  
• Form #9: Traumatic Incident
• Form #10: Formal Supervisory Referral Authorization
• Form #11: Authorization to Extend EAP Services
• Form #13: Consultation Request (Area Clinician only)
• Form #14: Consultation Service Receipt (Area Clinician only)

All bills will be paid from the Service Receipts (Please make sure they are filled out completely and legibly with appropriate signature). Receipts and a service receipt are required for all travel expenses. If you have questions please call. We must receive all forms before the 10th of the month in order to have enough time to process the bill properly. .

*Receipts for travel expenses must be submitted with service receipts for reimbursement, and must be summarized on service receipt.