Organisation providing benefit*
Employee Name
Employment Status
Full-Time Employee
Part-Time Employee
Temp On/Call-On/Adjunct
Terminated/Laid Off Employee (Eligible for 60 days)
Other
How did you hear about us?
Occuprof EAP Website
Occuprof Training Session
Occuprof (EAP Newsletter)
Brochure
Co-Worker
Employers Intranet
Family Member
Employee occupation?
Employee years at company?
0-12'Months
1-3'years
4-6'Years
7-10'Years
11-15'Years
16-20'Years
21-24'Years
Information on person (Client) seeking services
Who are you?*
Full-Time Employee
Part-Time Employee
Spouse / Significant Other
Child
Co-Parent
Terminated/Laid Of Employee (Eligible for 60 Days)
Temp/On-Call/Adjunct
Client First Name*
Client Last Name*
Date of Birth*
Client Email*
May we communicate via Email?*
Yes
No
Marital Status*
Single
Married
Common Law
Divorced
Separated
Widowed
# of Dependents*
Address*
City*
State*
Zip*
Client Primary Phone Type*
Cell
Home
Work
Client Primary Phone #*
May we call/leave message/text?*
Yes
No
Emergency Contact Name*
EC - Relationship to Client*
Daughter
Extended Family Member
Grand Parent
Legal Guardian
Parent
Sibling
Significant Other
Son
Spouse
Step-Parent
If there will be additional family members involved in this counseling, please list them here:
COUNSELLING INFORMATION
Preferred Counseling Format*
First Available
Telehealth
In-Person
Preferred Gender of Counselor*
Male
Female
No Preference
Preferred format is not guaranteed.
Preferred gender is not guaranteed.
Please choose your reason for seeking counseling*
Abuse (Child/Elder)
Abuse Other
Academics / Grades
Anger
Anxiety
Behavior Conduct
Compassion Fatigue
Covid-19 Concerns
Dependent Care
Depresion
Eating Disorders/Changes in eating habits
Family
Grief / Loss
Identity Theft & Fraud
Job/Career
Legal / Financial
Life Transitions
Loneliness / Isolation
Marital / Relationship Issues
Self-esteem / Confidence
Self-Injurious Behaviors
Sexuality / Sexual Orientation / Gender Identity
Social & Communication Skills
Stress
Substance Use
Substance Use Screening
Suicidal
Tobacco Readiness To Quit
Option
Would Not Disclose
Please briefly explain*
Have these issues been addressed in any prior counseling?*
Yes
No
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?*
Yes
No
If yes, please indicate the type of provider you see
Counselor/Therapist
Primary Physician
Clergy
Psychologist
Psychiatrist
Are there any medications being used to treat the counseling issues?*
Yes
No
If yes, please list the medications
Are you or those close to you concerned about your use of*
Any Substances
Other Addictions
None
Pre PHQ-9
Are your counseling issues related to discouragement, sadness or possible depression?*
Yes
No
If yes, please respond to the questions in the Patient Health Questionnaire (PHQ-9).
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?
N/A
Not at All
Several Days
More than halfthe days
Nearly Everyday
Little interest or pleasure in doing things?
N/A
Not at all
Several days
More than half the days
Nearly everyday
Feeling down, depressed, or hopeless?
N/A
Not at all
Several days
More than half the days
Nearly everyday
Trouble falling or staying asleep, or sleeping too much?
N/A
Not at all
Several days
More than half the days
Nearly everyday
Feeling tired or having little energy?
N/A
Not at all
Several days
More than half the days
Nearly everyday
Poor appetite or overeating?
N/A
Not at all
Several days
More than half the days
Nearly everyday
Feeling bad about yourself - or that you are a failure or have let yourself or your family down?
N/A
Not at all
Several days
More than half the days
Nearly everyday
Trouble concentrating on things, such as reading the newspaper or watching television?
N/A
Not at all
Several days
More than half the days
Nearly everyday
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?
N/A
Not at all
Several days
More than half the days
Nearly everyday
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?
N/A
Not at all
Several days
More than half the days
Nearly everyday
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*
Strongly Agree
Somewhat Agree
Neutral
Strongly Disagree
Somewhat Disagree
I am often eager to get to the work site to start the day*
Strongly Agree
Somewhat Agree
Neutral
Strongly Disagree
Somewhat Disagree
So far, my life seems to be going very well*
Strongly Agree
Somewhat Agree
Neutral
Strongly Disagree
Somewhat Disagree
I dread going into work*
Strongly Agree
Somewhat Agree
Neutral
Strongly Disagree
Somewhat Disagree
Yes
No
Yes
No
Submit
