Renewal Request Form

Sutter EAP

It's a new benefit year and renewing for 2024 is easy

You may use this form for two purposes:

At the beginning of each new benefit period, if you would like to continue seeing the same therapist you may use this form to contact us for a renewal authorization.
If you have additional sessions available, you may contact us to create an authorization for these additional sessions.

Note: You may enter multiple client names for the same therapist. If a family member is seeing a different therapist, please complete a separate form. If you would like to change therapists, please submit the Initial Request for Services form.

Your request will be processed and you will receive confirmation via email or phone (please indicate your preference below.) Should we have any questions, we will contact you via the method you indicate to ensure accuracy in the renewal process.

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:

Therapist's Name*
Employer Name*
First Name*
Last Name*
DOB* (MM/DD/YYYY)
Street Address*
City*
Zip Code*

Additional Referrals

You may enter additional family members here if they are seeing the same therapist

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*

Confirmation and Contact Information

Phone 1

Phone (ex: 916-555-0110)

Retype Phone

Extension

Retype Extension

Phone Type

Please specify 'Other'*

Phone 2

Phone (ex: 916-555-0110)

Retype Phone

Extension

Retype Extension

Phone Type

Please specify 'Other'*

Retype Email

Please indicate how you would like to receive a referral confirmation (please check at least one. Selecting 'Phone' grants permission to leave a brief voice mail). If we should need to gather additional information, we may contact you in this way as well. *

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 Comments (Limit: 250 characters)

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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