EAP CASE SUMMARY REVIEW

The EAP is a short-term solution-focused model. Should you identify long-term or specialized needs, please assist the client in connecting to services with the appropriate community or insurance-based resource. Self-referrals are permitted. To secure approval for additional sessions, you will need to complete the case summary form below. Following the review, a new authorization letter will be sent. If additional information is needed, an Acentra Health Consultant will contact you.

*Please do not include identifying client information or client names on this form.

Client Number: (Enter People ID #)*

Please enter the Client Number

Provider Assessed Problem*

Please provide the provider assessed problem

Evidence of risk to self or others*

Yes

If yes, please provide risk management plan

Short term counseling goals*

Please provide 2-3 short-term counseling goals

Total # Sessions Requested to Complete Counseling*

Please provide the total number of sessions required to complete counseling

Will this client require a referral to ongoing care or community resources, or will the short-term counseling goals be achieved within the EAP session model?*

Please select the appropriate option

EAP Services Only (can be resolved within the EAP session model)

EAP services plus Community Resources

MH/SA Referrals Recommended

Provider Signature*

Please enter the provider's first and last name in the signature field

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