CLOSED CASE Please complete all required fields and submitAuthorizaton Number*CounselorEmail Address Client Name* First Last Client Date of Birth* MM DD YYYY Employee Name First Last (if different from Client Name)Employer Name*Attended EAP session?*Yes, client attended EAP sessionNo, client never attended EAP sessionEAP Session DetailsPresenting Problem*Assessed Problem*Was client helped by your service?*YesNoImpact of problem on Job Performance:* None Mild Moderate Severe DSM–5 DiagnosisICD 10#DescriptionICD 10 #DescriptionICD 10#DescriptionICD 10#DescriptionICD 10#DescriptionReferrals Made: (check all that apply) Individual Counseling Group Counseling Marital/Family Counseling Psychiatrist Outpatient Alcohol and Drug Treatment Intensive Outpatient Alcohol and Drug Treatment Inpatient Alcohol and Drug Treatment Intensive Outpatient Psychiatric Treatment Inpatient Psychiatric Treatment Medical Self-Help Group Other Multi-Axial DSM IV DiagnosisAxis IAxis IIAxis IIIAxis IVAxis VDates Client SeenDate Seen* Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date Seen Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date Seen Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date Seen Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date Seen Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date Seen Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date Seen Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date Seen Date Format: MM slash DD slash YYYY No show or unexcused late cancellation List additional dates seen below. Put * next to no shows / unexcused late cancellationsOutcome*Problem Assessed / ResolvedProblem Assessed / Client ReferredShort Term Counseling / Problem ResolvedShort Term Counseling / Client ReferredProblem Unresolved / Client not ReferredReferral DetailsReferrals Made (check all that apply)* Individual Counseling Group Counseling Marital/ Family Counseling Psychiatrist Outpatient Alcohol and Drug Treatment Intensive Outpatient Alcohol and Drug Treatment Inpatient Alcohol and Drug Treatment Intensive Outpatient Psychiatric Treatment Inpatient Psychiatric Treatment Medical Self-Help Group Other If referred, specify facility or clinician name*Reason for Referral*Did client accept the referral?*YesNoIf no, please explain*Describe termination and disposition if problem was unresolved and client not referred*Follow up call made?*YesNoDate of first follow-up call* Date Format: MM slash DD slash YYYY Date of second follow-up call Date Format: MM slash DD slash YYYY If follow-up call not made, please provide reason*NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
