INSITE Integrative Services EAP Form
Ed Geraty LCSW-C, LICSW
Date of today
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Month
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Day
Year
Date
Name
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First Name
Last Name
Your Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number where you can receive text messages
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Please enter a valid phone number.
Your Date of Birth
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Month
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Day
Year
Date
Name of your EAP
Please add your EAP authorization number . If you do not know your number please contact your EAP for that number.
Number of authorized sessions
The name of your insurance carrier in the event that you continue services after your EAP sessions end.
Your insurance individual ID number
Insurance group number
Insurance carrier mailing address (usually on your insurance card)
READ CAREFULLY . Please be aware that there is a cancelation policy requiring a minimum of 24 hour notice of your intent to cancel a scheduled appointment. Otherwise your canceled session counts as a session and you are billed 75$ directly for that session unless your EAP has a different no show/late cancelation policy. If you are billed for a no show or late cancelation, the E-bill will come from EdGeratyLCSW-C@proton.me
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I am aware
My services are provided online in my HIPAA complaint video-therapy room. Please check "yes" indicating you are aware of this.
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Yes
Agreement
EAP sessions last for 45 minutes. Sessions must be video. Telephone sessions are not available. My practice is not an emergency practice. If you are experiencing thoughts to harm yourself or someone else, signing the Intake form implies that you agree to go to the nearest hospital emergency room or call 911. You have 24 hours to cancel an appointment. If an appointment is not cancelled prior to 24 hours, or if you do not keep your scheduled appointment, you are billed a 75$ no show-late cancellation fee . HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice). The Notice explains HIPAA and its application to your PHI in greater detail. Your typed name or signature on the Intake form acknowledges that I have provided you with this. If you have any questions, it is your right and obligation to ask so I can have a further discussion prior to signing the Intake form. I am not authorized to make any assessments for short- or long-term disability, leave of absence, FMLA, return to work, workers compensation, evaluations for school, or fitness for duty LIMITS ON CONFIDENTIALITY . 1. I do not. and will not, have communication with your employer. 2. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about our sessions. 1.If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I contact the authorities. 2. If I know or have reasonable cause to suspect that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the Maryland Abuse Hotline. Once such a report is filed, I may be required to provide additional information .3. If I believe that there is a clear and immediate probability of physical harm to the client, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient CHECKING THE BOX BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE NOTICE DESCRIBED ABOVE.
Reminder
A reminder to text me at 410-804-1934 and let me know you have submitted this Intake form. Ed Geraty LCSW-C By submitting this form you are indicating that you have read and agree to the above.
Signature
Please forward any authorization forms, email, etc to me at
EdGeratyLCSW-C@proton.me
Submit
Submit
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