------Hope Psychology Group: Metropolitan EAN Service agreement

Client First & Last Name: *

Date * +

Emergency Contact Name *

Phone *

Relationship to Client *

Signature of client who is 12 years or older *

clear

Date * +

Printed Name of Witness (Name of EAP Counselor) *

clear

Date * +

Parent/Guardian of Client who is age 12 to age 17 *

clear

Date * +

Signature of Witness (Name of EAP Counselor) *

clear

Date * +

Expiration Date of EAN Service Agreement (One Year From Above Dates) * +

Physician Contact - IF YOU ARE BEING SEEN IN ILLINOIS BY AN LCSW OR LCPC, PLEASE READ:
As required by Illinois Law PL 86-1434, and Insurance Code (215 [LCS 5, Sec. 370c), you are hereby informed that it is desirable that you consult with your primary physician about seeking and receiving mental health services. Metropolitan Family Services also recommends that you allow us to notify your physician that you are seeking or receiving mental health services. In order to notify your physician, you will need to give us permission by signing a separate "Consent for Release of Information" form.

If you do not want your counselor to contact your physician, you may opt out by checking the box and signing below: *

I do NOT want my physician to be notified or informed that I am seeking or receiving treatment.

Signature of Client *

clear

Date * +