Signature is required

Eligibility for Services

1. In order to receive counseling services from an ASAP Counselor you must either be an active employee, retiree, or an adult family member of an active UCD/UCDH employee. What is your relationship to UC Davis?

UCD Employee Full Name

UCD Employee Work Email Address

What campus does employee primarily work at?

2. In order to receive counseling services from an ASAP Counselor you must be physically located in the state of California at the time of your session(s). Please confirm you are located in California.* (If you are NOT located in California, please email asaphealth@health.ucdavis.edu for referral assistance.)

Client Information

First Name

Last Name

Preferred Phone Type

Preferred Phone # Number

Okay to leave message?

Preferred Email

Home Address

City

State

Zipcode

Age

Preferred pronoun(s):

If not listed, please write your preferred pronouns?

Gender Identity

If not listed, how would you describe your Gender Identity?

Please describe your current living situation:

Health Insurance Plan:

Race/Ethnicity

If not listed, or Multiracial please write your race/ethnicity:

Briefly describe your main reason for seeking counseling (100 characters or fewer):

Employment Information

UCD Work Email Address (Used only to verify employment. We will only email your preferred Email Address)

Department

Primary Work Location

Job Classification

If Job Classification not listed, please write your job classification:

Emergency Contact Information

Full Name:

Relationship:

Phone Number:

Counseling History with ASAP

Have you ever received counseling services from ASAP?

Are you currently seeing one of our counselors and would like to make a follow up appointment?

Current ASAP Therapist Name

Do you have a family member currently receiving ASAP counseling services?

What is the full name of the Family Member who received Services?

If yes, please list service type:

Individual

Couples

Family

Group

Case Management: Resource and Referral

Are you currently receiving counseling or mental health treatment (not including ASAP)?

If so please list name of psychiatrist and/or therapist:

Schedule Session Availability

Preferred Session’s Format (select all that apply)

In-person

Video (Zoom)

Phone

Preferred Days (please check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Soonest available

Preferred Times (please check all that apply)

6:30am-8:00am (limited availability)

8am-12pm

12pm-2pm

2pm-5pm

5:00pm-8:00pm (limited availability)

Soonest available

Will anyone else be attending the session with you?* (Check all that apply) Note: If another person will be attending the session, they must also submit this request form separately in order to provide consent for services.

Self

Co-worker

Family member(s)

Couple

Please share any information or requests, including If you have a disability-related accommodation (i.e., sign language interpreter, captioning, etc.) for your counseling appointment.

How did you hear about us?

If Other, please tell describe how you heard about us:

Are you a resident or a fellow?

Is this request for counseling services related to a workplace violent incident?

Informed Consent

I understand that ASAP provides free, confidential, short-term counseling to faculty and staff (including post docs and retirees) of UCD and UCDH and their adult family members and/or significant others. Counseling is provided to individuals, couples, families, and work groups.

I understand that my eligibility for participation is contingent upon my status as an employee or family member of the above stated eligibility pool.

I understand that confidentiality is kept within the ASAP staff and no information will be released outside of the ASAP without my written consent EXCEPT IN THE FOLLOWING CIRCUMSTANCES: REASONABLE SUSPICION OF CHILD ABUSE; REASONABLE SUSPICION OF ELDER/DEPENDENT ADULT ABUSE; THREAT OF VIOLENCE TO SELF OR OTHERS; and IF A COURT OF LAW ORDERS US TO RELEASE RECORDS.

I understand that my benefit is for short-term counseling. The first session is always an assessment of the issues and a decision will be made between client and clinician about next steps. ASAP focuses on short-term problem recognition and resolution. If extended counseling is needed or the staff at ASAP cannot meet the needs of the client, referrals will be provided.

I understand that there is no cost for ASAP services and if referrals are made, the cost of those referrals will be my responsibility.

I authorize ASAP to send an email or calendar invite for appointments and I understand that this information may not be confidential.

STATEMENT OF UNDERSTANDING

I understand the alternatives to counseling through telehealth as they have been explained to me, and in choosing to participate in telehealth, I am agreeing to participate using secure video conferencing technology.

I understand that with telehealth:

1) I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.

2) I have a right to confidentiality with regard to my EAP services and related communications via Telehealth under the same laws that protect the confidentiality of my information during in-person EAP services. The same mandatory and permissive exceptions to confidentiality outlined above also apply to my Telehealth services.

3) There will be no recording of any of the online sessions by either party.

4) I am responsible for using a location that is private and free from distractions or intrusions.

5) I am responsible for ensuring that my internet connection is private and secure.

6) The risks associated with participating in Telehealth include, but are not limited to: Technical interruptions due to internet bandwidth and continuity Limited ability by the clinician to respond to emergencies

7) The Counselor is required to verify my current location at the beginning of each Telehealth session.

By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or 9-8-8 or seek help from a hospital or crisis-oriented health care facility in my immediate area. I understand that ASAP is not an “on-call” clinic and that if I am having a psychiatric emergency, I will call 911 or go to the nearest emergency room.

Note: YOU MUST BE CURRENTLY LOCATED AT THE TIME OF YOUR APPOINTMENT WITHIN THE STATE OF CALIFORNIA TO RECEIVE SERVICES FROM ASAP. If you are out of state, you may send a message if you would like help with a referral.

Consent Full Name*

Sign Here Using Mouse or Finger/Stylus Use Keyboard

Submit

Academic and Staff Assistance Program Request for Counseling Services

If you or a loved one is experiencing a Mental Health emergency, call 911 or go to the nearest emergency room. If you need immediate emotional support call 988.

The Academic and Staff Assistance Program offers counseling support for UC Davis employees, their significant others, their adult dependent family members and retirees living in California. ASAP offers no-cost and confidential individual or couples sessions.

If you are located in California, you can get short-term help with job-related issues, personal concerns, and referrals to community resources.

If you are requesting couples counseling, both you and your partner need to submit a request for services.

This form and its client information are confidential and HIPAA compliant.