DEA Employee Assistance Program Forms

Forms can be faxed to 760-636-0437, or emailed to: deaeapbilling@thecounselingteam.com

If you have any questions or need additional information, please call us at 800-651-1021.

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#1 Admission

#2 Statement of Understanding Blank

#3 Service Receipt

#3b Area Clinician Multi-Use Service Receipt (3-28)

#3c Supplemental Mileage Form

#4 Client Satisfaction Survey

#5 Consent for Release of Confidential Information

#7 Threat of Violence Action Form

#8 Clinician Self Referral Disclosure Form

#9 Traumatic Incident Report Form

#10 Formal Supervisory Referral Authorization to Release Confidential Information

#11 Authorization to Extend Sessions

#13 Consultation Request Form

#14 Consultation Service Receipt

#15 Request for Training

Consent to use Teletherapy or Telephone Sessions

Confidentiality Guidelines (EAP)

EAP Policies and Procedures for DEA Remote Providers