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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)
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Additional Questions
Provider (Mental Health Professional) Preferences
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.
Details

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.
Please Explain any violence or abuse
Please Explain any concerns related to alcohol or other drugs

ASSISTANCE PROGRAM STATEMENT OF UNDERSTANDING AND AGREEMENT ON CONFIDENTIALITY:


  1. 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.
  2. 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.
  3. 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.
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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.
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