subject_line
Client First and Last Name
Date
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Emergency Contact name
Phone
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Relationship to client
+
Signature of Client who is 12 years or older
clear
Date
+
Printed Name of Witness (Name of EAP Counselor)
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 Date)
If you don't 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
+
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