Please disregard if this is not Lifeworks EAP

 

You have been referred by LifeWorks U.S. Inc. ("LifeWorks") for assessment and/or counseling services through its Employee Assistance Program (EAP). The EAP provides non-medical counseling for a specific issue that can be addressed within a limited number of sessions. This counseling is provided at no cost to you. You are expected to be on time for your appointments and give your counselor at least 24-hour notice if you are unable to keep an appointment. 

In the event that your counselor recommends continued counseling beyond the number of sessions authorized by LifeWorks or refers you for mental health treatment beyond the scope of the type of counseling provided through the EAP, it will be your responsibility to determine whether or not those outside services are covered under your medical benefit plan and to pay any charges for services not covered by your medical benefit plan. 

Confidentiality It is important that you understand the confidentiality of the communications between you and your counselor. Unless you authorize disclosure, no information about you or the records of your counseling sessions will be given to third parties, except under the circumstances identified below. 

The circumstances in which your counselor may be required to disclose confidential information to appropriate authorities without your permission are: 

Your counselor believes that you might harm yourself or someone else. Such a disclosure could include information 

indicating impairment sufficient to pose a life-threatening situation at your workplace. Your counselor believes that a child or a vulnerable adult is being abused and/or neglected. A judge orders your counselor to comply with a court order or subpoena to provide information in connection with a legal 

proceeding. You have been mandated to LifeWorks EAP services by your employer. Your counselor may share results of assessment and recommendations with your assigned LifeWorks case manager, although cannot disclose any information to your employer. 

You have a right to access your record maintained by LifeWorks. If you wish to have a copy of your record, you must contact LifeWorks. You may also request a copy of your EAP case record from the counselor who provided you services. The counselor will ask you to sign a release of information and can provide a copy of your record pursuent to applicable legal and professional obligations. 

Complaints of Harassment and/or Discrimination If you discuss with your counselor concerns about workplace harassment, violation of company policy, and/or discrimination, they will not be treated as official notification to your employer. To report such incidents, you will need to follow your company's policies. 

Counseling for Children LifeWorks does not authorize individual assessment for children less than 13 years of age, although they may be included in sessions with your family as a unit. A parent or legal guardian must participate in all sessions when children less than 13 years of age are involved in counseling. 

Children over 13 but under the age of majority may be authorized for individual assessment and/or short-term counseling with the signed consent of a parent or legal guardian, who must participate in at least the initial assessment session. 

Counseling for Couples LifeWorks may refer you and your spouse/partner for a joint assessment and/or couples counseling. In this case, both parties must attend at least the initial assessment session. You will both be required to sign this Statement of Understanding form.


I have read this Client Statement of Understanding (informed consent). My questions about this statement have been answered, and I understand its contents. 

I release and agree to hold harmless LifeWorks its staff, employees, and agents from any action or liability arising out of my participation in the Employee Assistance Program. 

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