EAP Forms & Instructions for Use

Client Intake Form
Use of the TSG Client Intake Form is optional.  Affiliates may use their own intake form that meets the needs of their practice. 

Employee Assistance Affiliate Statement of Understanding
Affiliates may use their own Statement of Understanding form; however, the TSG Statement of Understanding clearly defines the objectives and structure of EAP practice and the Affiliate’s role in that process.  We find that this Statement of Understanding reduces the number of questions or misunderstandings that clients may have about their EAP benefit and allows Affiliates to focus on their clinical assessment, counseling and/or referral.

EAP Member Rights Policy

Release of Information (ROI)
Please refer to items #6 and 7 on the Employee Assistance Affiliate Statement of Understanding for our policy regarding release of confidential information. 

Use this form any time information needs to be communicated to another mental health/medical provider or the client’s employer (supervisor/Employee Health or Human Resource Department).  In the case of Formal Supervisor Referrals, only attendance compliance may be released, unless the client specifies other information to be released.  In most cases involving an employer referral, the Affiliate should communicate the required information to the referring TSG staff person, who will relay the information to the employer.  An ROI is required for this purpose between the Affiliate & the entity who will ultimately receive the information.

Parental Consent Form
Please refer to item #8 on the Employee Assistance Affiliate Statement of Understanding for our policy regarding working with minor children who have parents and/or guardians who share joint legal custody. 

Our Referral Specialist will inquire about the legal custody status of the child before referring to an Affiliate.  If joint legal custody is the status, the Referral Specialist will send the Parental Consent Form to the parent who has requested counseling for their child.  That parent will be instructed to have the form signed by the legal custodians and to return it to TSG prior to scheduling the first appointment.  TSG will forward a signed copy to the Affiliate with the authorization for sessions.

If a custodial issue is not revealed at TSG intake and later becomes known by the Affiliate, please provide the Parental Consent Form to the parent as soon as it becomes known.  Instruct the parent to have the form signed by the legal custodians prior to scheduling another appointment.  Please collect the signed form, and forward a copy to TSG.  Affiliates should not proceed with services for a child without the signed Parental Consent Form.

Critical Incident Stress Debriefing/Trauma Recovery (CISD/TR) Handouts

Facilitator’s Opening Remarks - Review and introduce the format at the beginning of the CISD/TR group.

Practical Guide for Employees - Make enough copies to distribute to CISD/TR group attendees.

Family & Friends Handouts – Make same amount of copies to distribute to CISD/TR group attendees.

Supervisor’s Guide – Make at least one copy to provide to the employer contact person.

Mediation Forms & Handouts

Agreement to Mediate – Participants must review and sign prior to beginning mediation.

Pre-Mediation Helpful Instructions – Review these basic communication/attitude strategies with participants prior to starting the mediation.

Mediation Agreement Template – Use to document the agreements reached. All participants and mediating Affiliate must sign and date.


We welcome the opportunity to talk with you about your needs.
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