Palmetto EAP Intake – Deirdre Haynes Counseling Services

Palmetto EAP

Utilization Report Data

Deirdre Haynes Counseling Services

Patient Name:

First Last

DOB:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone:

I understand and give permission for this information to be provided to Palmetto EAP for general statistical purposes only.
Palmetto EAP is subject to all applicable Federal and State Confidentiality Laws.

Patient's Signature

First Last

(or legal guardian, if underage)

Job Title:

(Leave blank if you are a dependant)

Gender:

Are you?

Age:

Race?

If you are a dependent, what is the name of the family member with the EAP benefit?

Palmetto EAP Intake Form

Step 1 of 3

WHAT PROBLEMS ARE YOU HAVING?

Job Category

How did you learn of your EAP benefit?

Facebook