Forms and Resources for Members, Managers and Providers

Our goal is to make it easy for our members to get help from the Employee and Member Assistance Programs. The documents on this page will help managers, members and providers gather and record essential information.

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For Managers

Management Referral Form

For Members

Statement of Understanding

For Providers

Patient Information & Demographic Sheet
Billing Sheet
Statement of Understanding
Audit Checklist
Case Staffing Form
Documentation Form
Documentation Key
Intake Assessment
Authorization for Disclosure
Chemical Dependency, Medical, Psych History, Risk & Legal
Self-Referral Waiver

Talk to licensed counselor today.
Call 314-729-4600 #2
or 800-413-8008 #2