EAP Intake And Consent | Caris Pepper

EAP Client Consent Form

Purpose of Services

Therapy sessions are provided as part of your workplace’s Employee Assistance Program. Sessions focus on wellbeing, mental health support, and short term counselling. The EAP funding covers an agreed number of sessions.

Confidentiality

Your sessions are confidential. Your therapist will not disclose the content of your sessions to your employer or EAP provider.

The only information that may be shared is:

your attendance, and
broad themes or workplace risk issues if required by the EAP agreement.

No personal or clinical details are shared without your written consent.

Limits to Confidentiality

Confidentiality must be broken if:

there is a risk of harm to yourself or others
there is a legal obligation to disclose certain information
there are concerns relating to children’s safety

Session Structure and Fees

Sessions funded by the EAP are covered by your employer or the EAP provider.
If you choose to continue privately after your EAP sessions conclude, standard private fees apply.

Cancellations

Late cancellations or non attendance may count as a used EAP session, depending on the EAP provider’s policies.

Record Keeping

Clinical notes are kept by the therapist for professional, ethical, and legal requirements. These notes are not shared with your employer.

Consent and Acknowledgement *

I have read and understood the information above. I consent to participate in therapy under the Employee Assistance Program.
I give permission for my therapist to communicate with other health professionals if a crisis/emergency arises

EAP Client Intake Form

Client Name *

First

Last

Preferred Name

Phone *

Email *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency Contact *

First

Last

Relationship *

Phone *

Presenting Concerns (optional)

Are you experiencing any immediate emotional or physical safety concerns? *

If yes, please provide any information you feel is important for your therapist to know:

Do you have any learning, communication, cultural, spiritual, or physical needs that would support your comfort in sessions? *

Agreement *

I confirm the information provided is accurate to the best of my knowledge.

Date *

EAP Privacy and Confidentiality Statement

Your Privacy

Your personal information is collected to provide safe and effective therapy. Information is stored securely in line with Australian Privacy Principles.

Information Collected

contact details
emergency contact details
relevant wellbeing or safety information
session notes
EAP referral information

How Information is Used

Your information is used only for therapeutic purposes. No personal or clinical information is ever shared with your employer without your written consent.

Information Shared with EAP Provider or Employer

Only the following may be shared:

confirmation of attendance
number of sessions attended
broad themes or recommendations if required by the EAP agreement, without personal identifiers

Your Rights

You may:

request access to your file
request corrections to your information
withdraw consent at any time
ask questions about privacy at any stage

Contact for Questions or Concerns

If you have any concerns about privacy or confidentiality, please raise them at any time during your sessions.

Emergency contacts

If you are experiencing a crisis and need urgent support please call:

Australia

Lifeline 13 11 14 or Beyond Blue 1300 22 4636

New Zealand

Lifeline 0800 543 354, Suicide Crisis Helpline 0508 828 865, Samaritans 0880 726 666

Singapore

Samaritans of Singapore 1800–221 4444

Hong Kong

The Samaritans: 2896 0000, Suicide Prevention Service: 2382 0000

CONSENT AND INTAKE

Employee Assistance Program