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CLOSED CASE
Please complete all required fields and submit
Counselor
*
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 session
No, client never attended EAP session
EAP Session Details
Resolution
*
Client helped
Client never attended EAP session
Outcome
*
Problem assessed / Client referred
Problem assessed / Resolved
Short term counseling / Client referred
Short Term counseling / Problem resolved
Recommendation
*
None: Issue resolved
Counseling ( Individual, couple, family)
Medical
Mental health treatment program (IOP, Partial hospitalization, Inpatient)
Other
Psychiatry
Referral to community resource
Substance abuse treatment program (any)
Dates Client Seen
Date 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
*
Yes
No
Signature
*
Your name
*
First
Last
Section Break
Email
This field is for validation purposes and should be left unchanged.
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