Provider Forms

Counselors providing services for The Village EAP are required to complete referral packets for each new client. Required forms are listed below. Completed forms must be returned to The Village EAP by providers to establish eligibility for reimbursement.

The forms are pdf files and you will need Adobe Acrobat Reader in order to open them. Download this free program at www.adobe.com/products/acrobat/readstep2.html.

Instructions for Referral

Guidelines for processing a referral.

Intake Form

The top portion of this form is filled out by Intake staff during the initial phone call to The Village EAP. Following the first appointment, the counselor must complete the bottom portion by indicating the number of people in session, marking the Assessed Problems numerically (1-primary presenting problem, 2-secondary, etc.), indicating the Recommended Action, and signing/dating the bottom right corner.

Authorization for Disclosure

The purpose of this form is to authorize affiliate providers to give the client(s) name to The Village EAP for billing purposes. This needs to be signed by all those in session as well as the counselor as the witness. The form must be signed in order to process the billing.

Client Rights/Informed Consent

The Client’s Rights/Informed Consent provides written information of the rights of being a client of The Village. This form must be signed by all those in session as well as the counselor acting as The Village Representative.

Billing Form

You may use this form when billing for services provided to a client of The Village EAP.

Notice of Privacy Practices

The Notice of Privacy Practices provides clients with information of the rights regarding their personal/health information. This must be signed and dated by any client(s) in the session.