Initial Request for Services

Sutter EAP

This form is for initial EAP requests for services with a licensed therapist. We will contact you within 2 to 3 days to confirm receipt of the request and ask some additional questions to help connect you with the best resource(s). We will then locate a therapist within one business week and provide you with the details.

If your need is more urgent, please call us at 1-800-477-2258. If your request is for legal, financial or work/life services, please call us at the above number. If you call before 8:00 am or after 5:00 pm Monday through Friday or on a weekend or holiday, your call will be answered by an after-hours clinician who can provide in the moment support. They will also obtain basic information from you. An EAP Licensed Clinician will respond to your request the next business day.

Show Confidentiality Statement and Cancellation Policy Content

Confidentiality Statement:

Our services are 100% confidential. When you contact us, it's strictly between you and our staff - your employer will not be notified and all information you share with us will be kept in the strictest confidence. There are some limits to confidentiality. We are required by law to report suspected child or elder abuse to the proper authorities. Similarly, if we believe that someone might harm themselves or others, we are required to take appropriate action.

24-Hour Cancellation Policy:

"No Show" or "Late Cancellation" of appointments will be counted as one of the client's authorized sessions. Please note: Providers bill Sutter EAP for sessions missed by our clients.

Items marked with * are required

I am requesting services for:

First Name*

Last Name*

Date of Birth* (MM/DD/YYYY)

Employer Name*

Health Insurance Carrier

Employee name is different than above

Employee Information

Employee First Name*

Employee Last Name*

Employee DOB* (MM/DD/YYYY)

Relationship to person services are being requested for*

Identity

Please select one*

I am requesting services for myself

I am requesting services for someone else (who is under 18)

I am the employee* Yes No

I am

First Name*

Last Name*

Date of Birth* (MM/DD/YYYY)

I am requesting services for my*

Please specify 'Other'*

Contact Information

Phone 1

Phone (ex: 916-555-0110)

Retype Phone

Ext

Retype Ext

Phone Type

Please specify 'Other'*

May we leave a message at this number? Yes No

Phone 2

Phone (ex: 916-555-0110)

Retype Phone

Ext

Retype Ext

Phone Type

Please specify 'Other'*

May we leave a message at this number? Yes No

Retype Email

Preferred contact method (Please select at least one)*

Email Phone

Please note: If you request a reply by email, Sutter EAP will send you an encrypted email message. If you are using an email address outside the Sutter system, such as Gmail or Yahoo, you will be required to register to open the encrypted email. This is to ensure confidentiality. If you are unable to open the encrypted message even after registering, please call us at 1-800-477-2258.

Additional Referrals

Referral 0

First Name*

Last Name*

Date of Birth* (MM/DD/YYYY)

Relationship to Employee*

Referral 1

First Name*

Last Name*

Date of Birth* (MM/DD/YYYY)

Relationship to Employee*

Referral 2

First Name*

Last Name*

Date of Birth* (MM/DD/YYYY)

Relationship to Employee*

Referral 3

First Name*

Last Name*

Date of Birth* (MM/DD/YYYY)

Relationship to Employee*

Referral 4

First Name*

Last Name*

Date of Birth* (MM/DD/YYYY)

Relationship to Employee*

Additional Information

Description of where you would like to receive services (areas / communities e.g. "Downtown Sacramento", etc. - Limit: 250 characters remaining)*

Description of the area of concern and type of services you are requesting. This information helps us match your needs with a qualified therapist. We are unable to guarantee face-to-face sessions. If you prefer face-to-face sessions, please inform us. - Limit: 500 characters remaining)*

Is alcohol and/or drugs an area of concern?* Yes No

Preferred Therapist Gender

Availability

Please indicate your availability by selecting options below *

Tip: select a range - hold shift while clicking. Add or remove a selection - hold ctrl while clicking.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Policies

Confidentiality Statement:

24-Hour Cancellation Policy:

"No Show" or "Late Cancellation" of appointments will be counted as one of the client's authorized sessions. Please note: Providers bill Sutter EAP for sessions missed by our clients.

I understand that by transmitting this request to Sutter EAP, I am authorizing release of my name to a therapist upon acceptance as a client by that therapist. *

Please verify you are human

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