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Service Requester (Please remember that all of your information is confidential unless you request that we release information or in the event that you are a threat to yourself or someone else)
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ASSISTANCE PROGRAM STATEMENT OF UNDERSTANDING AND AGREEMENT ON CONFIDENTIALITY:


  1. Confidentiality Information you provide to your Assistance Program is confidential and will not be disclosed without your written consent except as set forth below:
    1. Abuse or neglect of a child, dependent adult, or person with a disability,
    2. Threat of bodily harm to yourself or someone else,
    3. As mandated by a court order or law, or
    4. With your signed consent.
  2. Fees
    1. Please consult with your insurance or benefits representative before you access services outside of the Assistance Program provider network.
    2. There may be costs associated with the referrals provided that are not covered by the Assistance Program.
  3. Complaints of Harassment and/or Discrimination Discussion of concerns about potential workplace/school harassment, violations of organizational policy and/or discrimination with your counselor are not considered official notification to your employer/school. To do so you will need to follow your organization’s policy.
By accepting below I acknowledge that I have read and understand the above statement and that I agree to proceed pursuant to the terms set forth above.
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We may match you with a third-party provider. We are not responsible for the data use practices of third-party providers. By pressing the “Submit” button, you consent to us sharing your personal information with a third-party provider.
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