EAP Evaluation/Treatment Plan Report



 

Today's Date: *  MM/DD/YYYY   
 
Client Name: *  
Client's Employer / Organization #: *  
Mines Client #: *  

 

CLINICAL INFORMATION: *
  
 (Please indicate chief complaint, including frequency, intensity and duration of problem. Include all issues pertaining to substance abuse, mood disorders, psychosocial stressors, impulse control issues and relevant family history)
DIAGNOSIS: (DSM-IV)
  Code Terminology
Axis I (a): *  
 
Axis I (b):
Axis II:
Axis III:
Axis IV:
Psychosocial Stressors:
 
  
Axis V:       Current GAF: *      Highest GAF Past Year: 

 

 

CURRENT MEDICATIONS:
Medications: * 
 
 
Prescribed by:  

 

 

TREATMENT GOALS/PLANNED INTERVENTIONS:

*Treatment Goals: Goals - expressed in measurable terms of frequency, intensity and duration as indicated.

1.*
 
2.
3.
4.

 

PLANS FOR CONTINUED CARE (please select one): *
Treatment goals reached through EAP sessions, CASE CLOSED. 
Seeking continued care through client's managed care / insurance.
If applicable, date for Mines PPO authorization to begin:
Requesting a new set of EAP sessions to address a separate and distinct problem.
Other (please specify): 
   
Provider Name:*   
Practice Name: *   
Phone: *   
Fax:

Email: *

  
When you click "Submit Form" below, a confirmation page will display. You can, at that time, print a copy of this completed form for your records At the top of your browser, click on "File" and then "Print". or cut and paste it into the application of your choosing.

                      


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