HOME : PROVIDER INFORMATION

Clinical Forms
Here are our clinical forms, those necessary for reimbursement and those recommended for creating a clinical record.

Clinical Forms In Spanish

Career Counseling Forms
Career Counselors can download instructions and the forms CONCERN requires for reimbursement.

Provider Manual - (PDF FILES)

General Information for Providers:

• The Role of an EAP provider
• Employee Assistance Program Core Technology
• EAP Provider Tips for Understanding & Managing Dual Relationships

Provider Communications:

• Quick Reference Guide
• Recent Quarterly Newsletter
• Frequently Asked Questions

Protocols and Guidelines:
Concern has developed the following guides and protocols to inform providers of our procedures and to offer evidence based practices for high risk situations.

• Clinical Protocol for Suicide Potential
• Clinical Protocol for Psychiatric Emergency, Threat of Violence, and Child or Elder Abuse
• Clinical Protocol for Domestic Violence
• Clinical Protocol for Substance Abuse Management
• Guide to Management and Documentation of Suicide Risk
• Guide to the Management and Documentation of Domestic Violence
• The Cycle of Violence
• Barriers Facing Battered Persons
• Guidelines for Making Referrals and Providing Coordination of Care
• Guidelines for Management and Documentation of Substance Abuse Cases
• Identification, Assessment, and Intervention with Alcohol Problems in an EAP Setting
• Provider Informational Guide for Supervisor Referrals

Client Handouts:

• How to Obtain a Mental Health Provider Using Your Mental Health Insurance Plan
• Notice of Concern Privacy Practices
• Work/Life Services
• Safety Planning Tips
• About Suicide
• When a Friend or Family Member Mentions Suicide
• Grievance-Complaint Form

Substance Use Assessment Tools and Resources:

• CAGE
• Alcohol Use Disorders Identification Test (AUDIT) Self-Administered
• Alcohol Use Disorders Identification Test (AUDIT) Interview Administered
• Drug Use Questionnaire (DAST)

Clinical Forms - (PDF FILES)

Directions for our Clinical Forms
If you are unfamiliar with our forms, read this first to determine which forms you will need.  These forms are required:

Clinical Statement of Understanding 
A Statement of Understanding must be signed by every client and retained in your records.

Client Data Form (Adult version)
Your client needs to complete this two page form at the first appointment and both pages need to be returned with the Problem Opening Form.

Client Data Form (Child Version)
Your client needs to complete this two-page form at the first appointment and both pages need to be returned with the Problem Opening Form.

Consent to Treat a Minor

Problem Opening Form - Page 1
Problem Opening Form - Page 2
To be completed after your assessment (1-2 visits).

Problem Closing Form
This form is returned after the last visit.

Closing Form Addendum
Complete when closing High Risk, Substance Abuse, or Supervisor Referral cases.

In addition to the forms above, below are examples of forms we recommend that every client record include:

Clinical Intake (two pages)
Case Summary

Client Satisfaction Survey
We ask that you give our clients a Satisfaction Survey. The Client Satisfaction Survey is printed on heavy stock so it can be mailed to us. Please call the provider request line 888-805-0090 option 2 and request that we mail this to you directly. The version available for download requires you return it in an envelope and provide postage.

Clinical Forms Spanish - (PDF FILES)

Statement of Understanding - Spanish (PDF)
Client Data Form – Adult (2 pgs) - Spanish (PDF)
Client Data Form – Child (2 pgs) - Spanish (PDF)
Consent to Treat a Minor - Spanish (PDF)
Description of Employee Services - Spanish
Client Satisfaction Survey - Spanish (PDF)

Career Counseling Forms - (PDF FILES)

Directions for Career Counselors
If you are unfamiliar with our forms, read this first to determine which forms you will need.

Career Counseling Statement of Understanding
A Career Counseling Statement of Understanding must be signed by every client and retained in your records

Client Data form for Career Counseling
Your client needs to complete this form at the first appointment and it needs to be returned with your bill for payment.

Client Satisfaction Survey
We ask that you give our clients a Satisfaction Survey at the third visit or as you deem appropriate.. The Client Satisfaction Survey is printed on heavy stock so it can be mailed to us. Please call the provider request line at 888-805-0090, option 2 and request that we mail this to you directly. The version available for download requires you return it in an envelope and provide postage.

Provider Satisfaction Survey
We are always interested in receiving your feedback. Complete this and return it to us with your feedback and suggestions.

Please contact us directly for information concerning the benefits of a particular employer or for the benefits of someone who has been referred to you.

PDF FILES -
The forms and information below are available as PDF files. They require the free program called Reader installed on your computer to view the files.  If you do not have Reader, click on this link and follow the directions to download and install Reader.