Couples - please print 2 copies one to be completed by each individual.

Transcription

1 Please print and complete the attached information forms and bring them with you to your initial appointment at the UAB Employee Assistance and Counseling Center. Couples - please print 2 copies one to be completed by each individual. If you are unable to bring the completed forms with you to your initial appointment, please arrive at least 30 minutes before your scheduled appointment time to allow time to complete the information before you meet with a counselor. Thank you. UAB Employee Assistance and Counseling Center (formerly the UAB Resource Center) th Ave South, Suite 330 Birmingham, Al

2 UAB Employee Assistance and Counseling Center (EACC) - Client Information TODAY S DATE: / / AGE: CLIENT FIRST NAME (MI) (LAST) DATE OF BIRTH / / GENDER: M F EMPLOYEE S FIRST NAME (MI) (LAST) ADDRESS CITY STATE ZIP OK to ? Y/N? HOME OK to call Home? WORK OK to call Work? CELL OK to call Cell? PHONE ( ) - Y/ N PHONE ( ) - Ext Y/N PHONE ( ) - Y/N? Health Plan: Employee s Workplace: Shift Viva UAB UAB Campus 1 Days Viva Access/Health School of Medicine 2 Evenings Blue Cross School of Nursing 3 Nights Peehip Viva School of Dentistry 4 Rotating Peehip Blue Cross School of Optometry 5 Other Other School of Health Professions 6 N/A Family Member School of Public Health Education School of Business How Long Have You Been In This 1 8 grades or under th th School of Engineering Job?: 2 9 through 11 College of Arts and Sciences 3 High School Graduate How Long Have You Worked With School of Education 4 Some College This Employer? Graduate School 5 College Graduate Administration 6 Advanced Degree UAB Other Have You Been To The UAB Ethnic Background Displaced Employee Assistance and 1 Counseling Center Before? American Indian or UAB Hospital Alaskan Native Hospital 1 Yes 2 No 2 Asian Highlands 3 Black or African American Displaced Work Performance Problems: 4 Hispanic/Latino Hospital Other (Put a #1 and #2 next to the top two 5 Native Hawaiian or UAB Callahan Eye Hospital that apply to you, with #1 being the Days Absent In Last 12 Months 1 No Days Days Days Days Days 6 N/A - Family Member Have You Lost Time At Work Due To Injury In Last 12 Months 1 Yes 2 No 3 N/A Family Member Are Any Of The Following Currently A Problem? 1 Suicidal thoughts 2 Homicidal thoughts 3 Sexual Abuse 4 Physical Abuse 5 Combination of Above 6 None of Above Pacific Islander UAB Health Services Foundation most serious) 6 Two or More Races Health Services Foundation 1 Absent 7 White Kirklin Clinic 2 Tardy 8 Other Health Services Foundation 3 Safety Violations Other HSF 4 Problems Relating to Marital Status Displaced Other Employees 1 Single UAB Health System 5 Quality/Quantity of 4 Monday Mailing 2 Married Health System Administration Work Decreased 3 Divorced Health System Other 6 Workers Comp Case 4 Separated Displaced 7 Alcohol/Drugs Suspected 5 Widowed Homewood School System 6 Life Partner 7 Living w/someone Length Of Time In Current Relationship Relationship to Employee: 1 Employee (Self) 2 Employee + Family Member 3 Family Member 4 Other Central Office Transportation School: Certified Non-Certified VIVA/Triton Job type Administrative/Support Exec/Management Faculty Professional Non Faculty Service on the job 8 Theft 9 Other 10 N/A Family Member 11 No Work Performance Problem /Personal Personnel Actions Taken (Mark the two most recent events #1 and #2, with #1 being most recent.) 1 Employee was counseled 2 Verbal/Written Warning Referral Source 1 Supervisor Formal Skilled Crafts 3 Suspension 2 Supervisor/Personal Concern Technical 4 Placed on Administrative 3 Self 4 Family 5 Co-Worker 6 Other 7 Physician If Referred By Supervisor: OK to contact Supervisor? Yes / No Supervisor s Name Nurse Physician School System Work Status 1 Full Time 2 Part Time 3 As Needed 4 Temporary Leave 5 Referred to EAP 6 Termination 7 Resignation 8 No Action Taken 9 N/A - Family Member 10 Other 11 Not Applicable How Did You Hear About The UAB Employee Assistance and Counseling Center?: 1 Prior Participation 2 The UAB Reporter 3 Posters 5 Brochures 6 Supervisor Suggested 7 Co-Worker Suggested 8 Family Suggested 9 In-Service Training/ Orientation 10 Other May We Send You A Confidential Follow Up Questionnaire by ? 1 Yes, send an link connecting to a confidential survey 2 No, I do not wish to participate Do you have children? Yes/No If so, please list their ages: Emergency contact Name Phone Number: ( )- - Primary concerns: Look at the list on next page and circle the two things that are concerning you most today. 5 Displaced Put a #1 by your most Supervisor s phone: 6 Other 7 N/A Family Member significant concern.

3 What Are You Most Concerned About Today? Look at the following list and circle the two things that are concerning you most today. Please circle ONLY the top two concerns that are most important to you today even if more seem to fit. Put a #1 by the issue that is most significant to you today. 1. Alcohol Abuse 24. Physical Abuse 2. Drug Abuse 25. Sexual Abuse 3. Abuse Other 26. Emotional Abuse 4. Gambling 27. Post-Traumatic Stress 5. Internet 28. Trauma Other 6. Sexual 7. Eating Disorders 29. Relationship with co-workers 8. Smoking 30. Relationship with Supervisor 31. Work Place Violence 9. Family Conflict 32. Harassment 10. Child 33. Job Performance 11. Teen 34. Work Related Other 12. Parent / Child Relationship 13. Domestic Violence 35. Medical Condition 14. Reaction to Illness 36. Financial Issues 15. Living with Abuse or Addiction 37. Childcare 16. Living with Emotional Problem 38. Older Adult Services 17. Family Other 39. Work Life Balance 18. Marital / Partner Relationship 40. Education 41. Work Life Other 19. Depression 20. Anxiety 42. No Personal Issue 21. Grief 43. Not Listed/Other 22. Stress 23. Emotional Other Revised August 2013

4 UAB Employee Assistance and Counseling Center - New Client Information Date: Name Name you prefer to be called If student, name of school _ Married/Life Partner? If yes, how long? Spouse/Partner s name Your occupation Spouse/Partner s Occupation _ Divorced Widowed Separated Single Life Partner Living with someone Number of Previous Marriages/ Partnerships Please describe the problem that caused you to seek help at this time. When did you first notice this problem? Have you ever been to counseling before? Yes No If yes, When? For what? Was it helpful? Estimate the severity of the problem: Mild? Moderate? Severe? Have you ever been hospitalized for psychiatric or substance abuse treatment? Yes No If yes, When? Where? For what? Are you currently under the care of a physician/psychiatrist? Yes No For what? Medications you currently take: Physician name Do you drink alcohol? Yes No If Yes, frequency: Daily? Weekly? Monthly? Occasionally? How many caffeinated drinks do you consume daily? Do you smoke? Yes No If yes, how many packs per day? Do you exercise on a regular basis? Yes _No _If yes, number of minutes per day? Week? Month? Are you diabetic? Yes No Do you use products containing sugar? Yes No If yes, amount

5 What do you want to get out of counseling? What country did you grow up in Describe your health: Excellent Good Fair Poor Circle any of the following that apply to you: Headaches Feel angry Sexual problems Diarrhea Feel tense Shy Fainting Feel panicky Trouble making friends Palpitations Tremors Trouble making decisions Feel anxious Bowel disturbance Feel sad Stomach trouble Depressed Trouble keeping a job Poor appetite Thoughts of suicide Feelings of inferiority Always worried Family discord Feel tired Unable to relax Financial problems Insomnia Unable to have fun Nightmares Drink too much Work too much Eat too little Eat too much Circle all of the following that have occurred within your family within the past year. Death of spouse/partner Death of close friend Divorce Marital/partnership separation Change in # of arguments with spouse/partner Jail term Foreclosure on Mortgage or Loan Death of family member Personal injury/illness Marriage/Partnership Job loss Change in work responsibilities Son/Daughter leaving home Marital/Partnership Reconciliation Trouble with in-laws Retirement of self/spouse/partner Change in family health Pregnancy Outstanding personal achievement Spouse/Partner stopping work Minor law violation Beginning/ending school Change in personal habits Sexual difficulties Vacation Gain of family member Change in finances Pending court case Trouble with boss/coworkers Change in residence Change in job Becoming a care giver for sick family/friend

6 Marital/Life Partner Survey Date: Name Age Occupation Highest level of Education Spouse/Partner Name Age Occupation Highest level of Education Date of Marriage/Partnership 1. Was either spouse/partner married or committed to a life partnership before? If yes: At what age, for how long and the reason for divorce or partnership desolation. 2. What are the reasons for choosing couples counseling at this time? 3. How have you tried to resolve your difficulties? 4. What are the major stressors for you, your spouse/partner and family at this time? 5. How would you like your spouse/partner to change? 6. How would you like to change yourself? 1

7 7. Have you considered divorce/separation? 8. What do you consider to be the strengths and weaknesses of your marriage/partnership? 9. What attracted you to your spouse/partner? 10. Do either of you have medical problems? If yes: What are they? 11. Do you or your spouse abuse alcohol or drugs? Gamble to excess? 12. Are either of you taking medications? If yes: What medications? 13. Is verbal abuse or physical abuse present in your relationship? If Yes: Describe the abuse. 14. Have either of you, alone or together, talked to a counselor, therapist, social worker, psychologist, or psychiatrist before today? If yes: Where and When? 15. Have either of you been in legal trouble? Is yes: For what. 2

8 16. How happy are you with the way in which you and your spouse/partner usually handle each of the following aspects of your family life? Please circle the number which best represents how happy you are in each of the following areas of your relationship. Mostly Happy Moderately Happy Mostly Unhappy Does not Apply A. Social interaction with each other B. Affectionate Interaction with each other C. Sexual interaction with each other D. Trust in each other E. Management of children F. Management of chores or other responsibilities at home G. Management of finances H. Social interaction with friends I. Social interaction with in-laws/ other relatives J. The way spouse/ partner manages self personally K. Spouse/partner management of jobs outside home L. Decision making M. Communications 3

9 At the UAB Employee Assistance and Counseling Center, we are proud to offer our clients the option of working with an intern who has completed Master s level or higher graduate counseling coursework and a practicum. This approach is of benefit to clients by providing them the expertise and experience of the UAB Employee Assistance and Counseling Center clinical team while allowing interns opportunities for supervised clinical experience to enhance their therapeutic skills. The client(s) would work with an intern and have a collaborative team of therapists, including an approved clinical supervisor, all working together for the benefit of the client. To enhance the therapeutic process, the clinical team collaborates on therapeutic goals and structures on an ongoing basis. As will all therapy at the UAB Employee Assistance and Counseling Center, our clients confidentiality is protected. All aspects of your treatment will be treated with the confidentiality dictated by the ethics of the counseling profession and state and federal guidelines. The UAB Employee Assistance and Counseling Center clinical team will determine the appropriateness of each client(s) for working with an intern in therapy. Please indicate your interest in working with an intern below: Yes, I would like to work with an intern if considered an appropriate candidate. I would like more information about working with an intern to make my decision. No, I am not interested in working with an intern at this time.

10 UAB EMPLOYEE ASSISTANCE AND COUNSELING CENTER STATEMENT OF UNDERSTANDING Welcome to the UAB Employee Assistance and Counseling Center (EACC). We are pleased that you have decided to use our service. The UAB EACC is a voluntary confidential employee assistance and counseling program. Our service is an employee benefit designed to provide employees and their immediate household members with resources for resolving work-related and personal problems. The EACC provides employee assistance, confidential counseling, community referral, supervisor consultation, crisis management and a variety of educational programs. Our service is designed to support and provide practical tools for balance in all areas of life. Licensed counselors provide confidential individual, family and relationship counseling. Our goal is to assist our clients in clarifying issues, exploring options, and finding solutions. Our service is provided as an employee benefit of UAB, UAB Medicine, VIVA and the Homewood School System at no cost to our clients. Intake, Counselor Assignment and Process There are several steps in the counseling process at the UAB Employee Assistance and Counseling Center. As a new client, a counselor will see you for an initial intake assessment. Counseling interns may observe or conduct the initial intake assessment. At this visit the counselor will spend time exploring with you the problems that caused you to seek counseling, your goals, and other information relevant to your situation. This information will be reviewed with our clinical team following your initial visit. Based on your assessment information we will match you with the UAB EACC counselor best suited to your needs. Our counseling staff may consult with one another throughout your treatment here to increase the effectiveness of our service to you. After the initial intake session, please call the UAB Employee Assistance and Counseling Center office the Thursday following your appointment for your counselor assignment and to schedule your next appointment for counseling. ( or toll free within Alabama ) Counseling sessions are generally 45 to 50 minutes in length. Intervals between sessions will be scheduled depending upon your needs. Generally such intervals will be scheduled once each week, once every two weeks, or at an interval decided upon by you and your counselor. The number of sessions will be determined by you and your counselor according to your progress in meeting your goals. If at any time you decide to terminate the counseling relationship, it is recommended that you inform your counselor in order to tie up loose ends and to allow for feedback concerning the counseling process. Children under the age of 15 may be referred externally for individual counseling unless seen within the context of family therapy. Scope of Benefit and Eligibility The UAB Employee Assistance and Counseling Center provides services for all eligible persons, without regard to race, color, religion, sex, sexual orientation, national origin, disability, or veteran status. If for any reason at any time the counselors of the UAB EACC determine that an individual s needs exceed the services or expertise available at the UAB EACC, the counselors will work with the individual to identify 5 Initials Revised 2/2016

11 an appropriate referral to meet their needs. Services provided to you at the UAB EACC are a benefit at no cost to you by UAB, UAB Medicine, VIVA and the Homewood School System with the exception of Divorce Mediation. However, the UAB Employee Assistance and Counseling Center does not cover the costs of therapy or community resources/treatment services to which you may be referred. UAB, UAB Medicine, and VIVA employees and members of their immediate households are eligible for up to 12 sessions each year. Detailed information regarding Homewood School Systems benefits is located on our web site; Confidentiality The UAB Employee Assistance and Counseling Center counselors understand that the assurance of confidentiality is essential to your counseling progress. Our counselors are dedicated to upholding their professional code of ethics and The Employee Assistance and Counseling Center s policy of ensuring your confidentiality. A written and electronic record (date, time, nature of meeting) of your contacts with the UAB Employee Assistance and Counseling Center will be maintained in a secure manner. Access to the record will not be given to anyone outside of the UAB Employee Assistance and Counseling Center, except as required by law or as described below. Should you need to access your file please contact your therapist. Your therapist will review the file with you and provide a written summary if requested. Limits of Confidentiality All information disclosed in counseling sessions is strictly confidential and will be released ONLY with your prior written permission, except as otherwise required by law. The counselor's legal responsibility to disclose information includes, but is not limited to, the following conditions: suspected or known child, elder or disabled person abuse or neglect, threat of danger to another individual, imminent threat of suicide by the client, legal subpoena to present records to comply with a court order, mandatory state and federal requirements, and in any emergency medical circumstance that requires immediate medical attention. If you received couples or family counseling records require a written release by all parties or a Judge s order to be released. Due to the strict adherence to our policy of client confidentiality, we are unable to report suspected cases of sexual harassment in the workplace. If you believe you have a sexual harassment complaint, UAB Policy encourages you to promptly report this situation to the designated official. If you are a UAB employee, contact the UAB Office of Human Resource Management Relations at , Room 260X Administration Building, to report sexual harassment. If you are a UAB Medicine, VIVA or Homewood School System employee, ask your Human Resource Office for information on how to report sexual harassment. Legal Testimony It is not the practice of the UAB Employee Assistance and Counseling Center to provide legal testimony for Employee Assistance and Counseling Center clients. Our therapist are not trained as forensic experts so if you know that you will require the testimony of a therapist in a court case please 6 Initials Revised 2/2016

12 let us know so that we can provide you with a referral to a therapist appropriately trained to represent your best interest in such situations. You will be responsible for a fee of $250 per hour should one of our therapist s be called upon to provide testimony for you in a court of law. This fee also applies to any travel, preparation, and consultation time required of our therapist as a result of court action. The cost to you for record reproduction is $25 per page. The UAB Employee Assistance and Counseling Center does not offer a court approved Anger Management Class. If a client has been court ordered to participate in Anger Management Classes and/or Counseling for domestic violence or any other reason, the UAB Employee Assistance and Counseling Center will provide counseling in addition to the client s participation in an Anger Management Class, but will only provide counseling if the client is also participating in an Anger Management Class elsewhere. The UAB Employee Assistance and Counseling Center will not provide counseling as a substitute for Anger Management Classes. Group Therapy Various forms of group therapy are periodically offered at the EACC. The success of group therapy depends upon a high degree of trust between you, the group counselor, and fellow group members. Counseling interns may observe or conduct group therapy with EACC supervisors. Your group counselor s primary responsibility is to create an atmosphere of safety and support in order for you to get the most out of group. Your group counselor will encourage each group member to be honest, vulnerable, and respectful about his or her feelings and observations in the group. It is important that each individual s boundaries and limits are voiced and respected in the group. All members of the group will be asked to agree to a high level of confidentiality in the group sessions. This means that each participant agrees not to share any other group member s identifying and personal information with others. It is appropriate to share with others your personal reaction and feelings about group, but refrain from sharing other people s stories with others who are outside of the group. Your Responsibilities as the Client This service is provided to you as a benefit at no cost to you by UAB, UAB Medicine, VIVA, and Homewood School System. You are expected to attend all appointments as scheduled and on time. If you are unable to attend a scheduled appointment, it is important that you call as soon as possible to cancel that appointment, as there are others who are also in need of our services. If you fail to show up for 2 scheduled appointments without calling to cancel, we will be unable to schedule another appointment for you for a minimum of 6 weeks. As a client of the UAB Employee Assistance and Counseling Center, it is also your responsibility to maintain the confidentiality and anonymity of other clients that you encounter while visiting our offices. If at any point in the counseling process you have questions or concerns regarding your counseling objectives, your counselor, or the counseling process, it is your right and responsibility to bring those concerns to your counselor in the counseling sessions. 7 Initials Revised 2/2016

13 It is your right to question your counselor, your counselor's qualifications, anything addressed in this statement, and anything that is not previously addressed in this handout. We encourage you to exercise this right. I have received a copy of the UAB EACC Statement of Understanding, which contains information concerning the UAB EACC and the counseling process, including but not limited to the following topics: Intake procedure, Counselor assignment and process; Scope of Benefit; Legal Testimony "No Show" Policy Confidentiality for the counseling relationship The Limits of Confidentiality Verification of attendance in cases of supervisor referral Confidentiality expected of clients towards other clients UAB Employee Assistance and Counseling Center clients Reporting of Sexual Harassment complaints I understand that it is my responsibility to read this information prior to my first counseling session and to ask an Employee Assistance and Counseling Center counselor to further explain any portions which I do not understand. I also understand that by participating in the UAB Employee Assistance and Counseling Center services, I am agreeing to abide by the guidelines set forth in the UAB Employee Assistance and Counseling Center Statement of Understanding. I hereby acknowledge that I have read and understand this Statement of Understanding. I acknowledge that I have received a copy of this agreement. I hereby release and hold harmless the University of Alabama at Birmingham, the UAB Employee Assistance and Counseling Center, Homewood City Schools, and their employees, agents, and assigns from any and all legal liability that may arise from my participation in the services offered by the UAB Employee Assistance and Counseling Center or by Homewood City Schools as part of its contractual relationship with the UAB Employee Assistance and Counseling Center. I certify that this release has been made freely, voluntarily and without coercion and the information given above is accurate to the best of my knowledge. Participant Name (Please Print) Participant Signature Personal Representative Name (Please Print) Personal Representative Signature Date Date Date Date 8 Initials Revised 2/2016

14 If you are signing this form on behalf of someone other than yourself, please enclose with this form proof of your authority to do so and attach written documentation (i.e. Guardianship Order, Custody Order, Court Order) as appropriate. Witness Date THANK YOU FOR CHOOSING TO USE THE UAB EMPLOYEE ASSISTANCE AND COUNSELING CENTER WE LOOK FORWARD TO WORKING WITH YOU The UAB Employee Assistance and Counseling Center th Avenue South Suite 330, Birmingham, Al 35205; (205) ; FAX: (205) ; 9 Initials Revised 2/2016