Call: 1-800-222-9691 | Stand By Status (SBS) Available 24/7/365

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.

DEA Forms

#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