CLOSED CASE Please complete all required fields and submitCounselor*Email Address* Phone*Authorizaton Number*Client Name* First Last Client Date of Birth* MM DD YYYY Employee Name ( if different than client) First Last Attended EAP session?*Yes, client attended EAP sessionNo, client never attended EAP sessionEAP Session DetailsResolution*Client helpedClient never attended EAP sessionOutcome*Problem assessed / Client referredProblem assessed / ResolvedShort term counseling / Client referredShort Term counseling / Problem resolvedRecommendation*None: Issue resolvedCounseling ( Individual, couple, family)MedicalMental health treatment program (IOP, Partial hospitalization, Inpatient)OtherPsychiatryReferral to community resourceSubstance abuse treatment program (any)Dates Client SeenDate 1* Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date 2 Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date 3 Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date 4 Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date 5 Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date 6 Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date 7 Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date 8 Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date 9 Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date 10 Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date 11 Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Date 12 Date Format: MM slash DD slash YYYY No show or unexcused late cancellation Follow up calls made*YesNoSignature*Your name* First Last Section BreakPhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
