Protector Overwatch Wellness Consultation and Referral Form

Protector Overwatch Wellness Consultation and Referral Form

This referral form is for Law Enforcement, Fire Fighters, Paramedics, Dispatchers, Corrections, Military Service Members, Veterans and their Family Members.
Are you looking for Therapy or a Wellness Consultation (also known as a check up from the neck up)*

TherapyWellness Consultation
I acknowledge that Wellness Consultations are for first responder agencies contracted with Ellie Mental Health, and you may need to provide verification for services to be covered*

I understand
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Wellness Consultation Department/Agency*

Airport Police Department/MACDakota County CommunicationsEagan Police DepartmentFreeborn County Sheriff's OfficeMendota Heights Police DepartmentMinneapolis Police DepartmentSt. Paul Police DepartmentWest St. Paul Police DepartmentOther
Are you Sworn or Civilian?*
Branch of service*
Department/agency/branch of service of family member*
Full Mailing Address*
Preferred contact method*

PhoneEmailText
May we leave a message?*

YesNo
Do you prefer to see a male or female therapist?*

MaleFemaleNo preference
Do you prefer in-person or Telehealth?*

In-personTelehealthNo preference
Which office location(s) do you prefer for In-Person meetings?*

Brooklyn CenterBurnsvilleChanhassenCoon RapidsEdinaGrand RapidsGolden ValleyMankatoMaple GroveMaplewoodMendota HeightsMinneapolisMinnetonkaMoorheadRochesterSauk RapidsShoreviewSt. PaulWest St. PaulWinonaWoodburyVirtual
Which office location(s) do you prefer for In-Person Wellness Consultation meetings?*

Brooklyn CenterBurnsvilleChanhassenCoon RapidsCottage GroveEdinaGrand RapidsGolden ValleyMankatoMaple GroveMaplewoodMendota HeightsMinneapolisMinnetonkaMoorheadRochesterSauk RapidsShoreviewSt. PaulWest St. PaulWinonaWoodburyVirtual
Name of specific provider you'd like to see or male/female preference
Many times, individuals might like to continue working with the provider they were matched with during their wellness consultation. Providing us with your health insurance information now will allow for an easy transition into these services.
Insurance Type
Member ID
Group Number
Policy Holder First and Last Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Policy Holder Mailing Address (if different than client's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder Relationship to Client
Please list 3-4 upcoming dates & times that you are available for a 50-60 minute Wellness Consultation. If you work overnights, please give your availability at the beginning or end of your shift. *
**Your Wellness Consultation will be scheduled within one of these time frames & confirmation will be emailed to you. If there are no available appointments during the above dates & times, you will receive a phone call from Ellie Mental Health staff to find another time that works for you.
Please list 3-4 dates & times during the month of your birthday that you are available for a 50-60 minute Wellness Consultation. If you work overnights, please give your availability at the beginning or end of your shift. *
**Your Wellness Consultation will be scheduled within one of these time frames & confirmation will be emailed to you. If there are no available appointments during the above dates & times, you will receive a phone call from Ellie Mental Health staff to find another time that works for you.
Before engaging in a Wellness Consultation at Ellie Mental Health, it is important for you to understand the following information.

Wellness Consultations are part of a wellness initiative offered by your employer. Your employer will NOT be notified of any personal information shared or the topics of interest indicated by you during your Wellness Consultation. The only information your employer will receive is your name, date of appointment, and whether you attended the appointment.
Wellness Consultations are not mental healthcare services:
- There is no formal assessment or evaluation of your mental health needs.
- You will not receive a diagnosis for a mental health disorder.
  Engagement in a Wellness Consultation will not be documented in your medical record.
- You will not be engaging in medically necessary or therapeutic services, and no part of your Wellness Consultation will be considered treatment of any medical or mental health disorder.
Rather, Wellness Consultations are an opportunity for you to work with a knowledgeable professional who will provide best practices for promoting overall emotional and mental wellness. You will identify the areas of life in which the consultation will focus upon.
If you think you may benefit from traditional mental health therapy instead of a Wellness Consultation, Ellie Mental Health will help you identify what those therapy services might be and make referrals for further support, at your request. You are not limited to receiving only one type of service. For instance, you could sign up for Wellness Consultations now and decide to seek out mental health therapy later, or vice versa. We just want to make it clear that Wellness Consultations are not mental health therapy services. Additionally, we make no promises that engaging in Wellness Consultations will change your behavior, circumstances, or that a specific outcome will happen.
By signing this form below, I agree that I understand the preceding information outlined regarding engaging in a Wellness Consultation at Ellie Mental Health.*

Clear
Date*

MonthDayYear
Date
Reason for seeking services (select all that apply)*

Addiction/Alcohol or DrugsAddiction/Gambling or PornographyADHDAnger ManagementAnxietyBurnoutCareer ConcernsCompassion FatigueCoping skillsDepressionDivorceGrief/LossMarital ProblemsPTSD/TraumaRetirementSelf-HarmSleep IssuesSuicidal ThoughtsWork/Life StressOther
What type of counseling are you seeking? (Individual, couples, or family)?*

IndividualCouplesFamily
Are you using Insurance, EAP, or Department Covered Sessions*

InsuranceEAPDepartment Covered SessionsNone
Insurance Type*
Member ID*
Group Number*
Policy Holder First and Last Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Policy Holder Mailing Address (if different than client's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder Relationship to Client
EAP Type*
Authorization Code*
Number of Sessions*
Authorization Code (If Applicable)
Department/Agency*
Are you Sworn or Civilian?*
Department/Agency*

Law EnforcementEMSFire911 DispatcherCorrectionsVeteranCivilian working with the populationFamily member of someone in the populationOther
Department/agency*
If no, what is your relationship to a first responder or veteran*
Type (Law Enforcement, Fire, EMS, 911 Dispatcher, Corrections Officer, or Veteran)*
Department/Agency/Military Branch of Service*
Which office location(s) do you prefer for In-Person meetings?*
Department/Agency*

Airport Police Department/MACDakota County CommunicationsEagan Police DepartmentFreeborn County Sheriff's DepartmentMinneapolis Police DepartmentSt Paul Police DepartmentWest St Paul Police Department
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Protector Overwatch Wellness Consultation and Referral Form

Before engaging in a Wellness Consultation at Ellie Mental Health, it is important for you to understand the following information.