Signature is required

Service Requester (Please remember that all of your information is confidential unless you request that we release information or in the event that you are a threat to yourself or someone else)

OSU Location

Relationship to OSU

What can we do for you?

Counseling Modality

Do you want to be seen by your Internal Ohio State University EAP counselors?

Please tell us a little more about yourself

First Name

Last Name

Date of Birth

Phone Type

Phone

Extension

OK to leave message?

OK to text?

OK to email?

Address where you’re CURRENTLY living

City/Town

State/Province

ZIP/Postal Code

Preferred method of communication

How did you learn about the Assistance Program?

Who referred you to the Assistance Program?

Additional Questions

How many hours of work did you miss in the past 30 days?

My personal problems kept me from concentration on my work

I am often eager to get to the worksite to start the day

So far, my life seems to be going well

I dread going into work

Did you work any part of your normal employment schedule in the past 30 days?

How would you rate your overall job performance on the days you worked during this timeframe? (0 is the worst job performance possible and 10 is the performance of a top worker)

Provider (Mental Health Professional) Preferences

Provider ZIP/Postal Code

Distance willing to travel

Gender Preference

Additional Provider Preferences

Availability

Who will be attending counseling in addition to you?

Please note that you are not permitted to request individual counseling services for another adult. Individuals 18 and over MUST request their own services. Individuals 18 and over can be included in couples or family requests.

Will someone be attending counseling in addition to you?

Will someone be attending counseling in addition to you?:

Yes

Attendee #1 First Name

Attendee #1 Last Name

Attendee #1 Date of Birth

Attendee #1 Relationship

Attendee #2 First Name

Attendee #2 Last Name

Attendee #2 Date of Birth

Attendee #2 Relationship

Attendee #3 First Name

Attendee #3 Last Name

Attendee #3 Date of Birth

Attendee #3 Relationship

Attendee #4 First Name

Attendee #4 Last Name

Attendee #4 Date of Birth

Attendee #4 Relationship

Attendee #5 First Name

Attendee #5 Last Name

Attendee #5 Date of Birth

Attendee #5 Relationship

Details

Please provide a brief description of the issue(s) for which you are seeking support

Are you currently experiencing any thoughts of hurting yourself or anyone else?

Are you currently experiencing any thoughts of hurting yourself or anyone else?:

Yes

DO NOT COMPLETE THIS FORM: If you are experiencing a life-threatening situation, please call 911 or immediately go to an emergency room.

If you need to speak with someone immediately, call the National Crisis Hotline by dialing 988.

Are you currently experiencing any violence or abuse?

Are you currently experiencing any violence or abuse?:

Yes

Please Explain any violence or abuse

Are you currently experiencing any concerns related to alcohol or other drugs?

Are you currently experiencing any concerns related to alcohol or other drugs?:

Yes

Please Explain any concerns related to alcohol or other drugs

Additional comments

ASSISTANCE PROGRAM STATEMENT OF UNDERSTANDING AND AGREEMENT ON CONFIDENTIALITY:

Confidentiality Information you provide to your Assistance Program is confidential and will not be disclosed without your written consent except as set forth below:
1. Abuse or neglect of a child, dependent adult, or person with a disability,
2. Threat of bodily harm to yourself or someone else,
3. As mandated by a court order or law, or
4. With your signed consent.
Fees
1. Please consult with your insurance or benefits representative before you access services outside of the Assistance Program provider network.
2. There is no charge to you for initial Assistance Program counseling visits up to the number of visits indicated in your benefit plan description. Your organization pays for these services. If you need longer-term counseling or a specialized service, if appropriate, you can continue with your current provider or AllOne Health will assist in locating additional resources or services. It will be your responsibility to determine whether or not those services are covered under your medical benefit plan and to pay any charges for services not covered by your medical benefit plan.
3. Some services, such as psychological testing, are not covered under the Assistance Program. Fees for such non-covered services will be discussed with you in advance. If you consent to non-covered services, you are responsible for any and all fees.
Complaints of Harassment and/or Discrimination Discussion of concerns about potential workplace/school harassment, violations of organizational policy and/or discrimination with your counselor are not considered official notification to your employer/school. To do so you will need to follow your organization’s policy.

By accepting below I acknowledge that I have read and understand the above statement and that I agree to proceed pursuant to the terms set forth above.

Consent Full Name*

Sign Here Using Mouse or Finger/Stylus Use Keyboard

We may match you with a third-party provider. We are not responsible for the data use practices of third-party providers. By pressing the “Submit” button, you consent to us sharing your personal information with a third-party provider.

Submit

Confidential Online Request Form for Counseling

If you are experiencing a life-threatening situation, please call 911 or immediately go to an emergency room.

If you are experiencing suicidal thoughts, homicidal thoughts, or domestic violence, DO NOT complete this form. Please contact your Assistance Program.

An Assistance Program representative will reach out to you within one business day with regard to your on-line request.

DO NOT COMPLETE THIS FORM: If you are experiencing a life-threatening situation, please call 911 or immediately go to an emergency room.

If you need to speak with someone immediately, call the National Crisis Hotline by dialing 988.