STATEMENT OF UNDERSTANDING:Welcome! We are pleased you have decided to visit us. Before your session begins, we request that you review the following information, and if you have any questions, please ask your consultant.
Sharing personal problems can be difficult and we make every effort to maintain your confidentiality. Unless you give us written permission to do so, we do not share information you discuss except for reasons cited below:
- If the EAP consultant believes that you or another person is at risk of harm or in cases where there is evidence of child abuse or elder abuse, we are required by law to inform an appropriate agency or individual. EAP must also comply with a court order and release the requested information.
- If your supervisor makes a formal or a mandatory referral to EAP because of work performance problems or safety concerns, your consultant will advise the company representative whether the appointments are kept, whether issues are identified, and whether recommendations are being followed. No personal information is shared.
Your sessions with the EAP consultant are offered at no direct cost to you or to your family.
No-show appointments shall be counted as a used session against the bank of available sessions when the employee or family member does not notify the EAP office 24 hours prior to the appointment time of their intent to cancel. If you need longer-term counseling or specialized services, the EAP will assist you in locating a resource in the community. Your health insurance plan may defray some or all of the cost of service; however, it is your responsibility to verify that insurance will cover the cost of therapy or other treatment and to pay any charges not covered.
Participation in the EAP is voluntary and employment or advancement with your company is not affected by your decision to use (or not to use) the services of Carilion EAP or its contracted affiliates.
BY MY SIGNATURE BELOW:I understand that my consultant will provide an assessment, and recommendations for ongoing referrals if he/she believes I would benefit from further assistance. I also understand that in seeking services with the Employee Assistance Program, I am involved in decisions on my continued course of services; I consent to use or disclosure of my protected health information to carry out services or health care operations by Carilion Employee Assistance Program or by its contracted subcontractors. I acknowledge that care will be provided in accordance with all federal and state confidentiality regulations including HIPPA and HITECH that assures notification of any unauthorized disclosures.
I acknowledge that I have read the above Statement of Understanding and therefore give consent for counseling. For individuals under the age of 18, parent/legal guardian must provide the signature below.