Beacon On-Site EAP Case Activity Form

1 Enter Information
2 Review Details
3 Submit

(Use only if EAP services delivered by Beacon On-Site EAP)

Instructions: Please use CAPITAL letters and complete ALL information. This form is for on-site case activity documentation only. Use CAF-1 form for billing of pre-authorized services delivered off-site. This form should be submitted at least every 30 days for members in active therapy or closed cases.

*Required Field


Status Type*
Statement of Understanding Signed*
Release of Information Signed*
 
(corporate client, employer, company/division, location or department through which EAP benefits are available)
Please enter a Payer
Please enter a Participant Last Name
Please enter a Participant First Name
Please enter a Participant Middle Initial
Please enter a Participant Street Address
Please enter a Participant City
Please enter a Participant State
Please enter a Participant ZIP Code
(mm/dd/yyyy)
Please enter a Participant Date of Birth
Please enter a Participant Home Phone
Format: xxx-xxx-xxxx
Participant Relationship to Employee*
 
Relationship Status*
 
Referral Source*
 
Learned About EAP*
Method of Initial Contact*
 
Participant Gender
Please enter a Employee SSN
Note: (if year is unknown, enter 'unknown')
Please enter a Employee Year of Hire
Please enter a Employee Last Name
Please enter a Employee First Name
Please enter a Employee Middle Initial
Employment Status*
 
Job Dysfunction*
 
Job Problem*
 
Job Title Category*
Union Member
 
Session Information: Date(s) of Service (mm/dd/yyyy)*
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
*
Please enter Number of EAP Sessions Used at Case Closing

Presenting and Assessed Problem*

choose only one Presenting problem (P) and one Assessed problem (A)
 P      A
Alcohol
Drugs
Mixed Alcohol / Drug Abuse
Anxiety
Depression
Eating Disorder
Hyperactivity/Learning
Impulse Control
Thought Disorder
Child Care
 P      A
Adult / Elder Care
Family Problem
Financial Problem
Grief / Loss
Job / Occupational
Legal
Marital / Relationship
Situational / Adjustment
Medical Problem
Stress

Risk and Functional Assessment*

Indicate participant’s level of impairment at case opening and at case closing.
0 = No evidence of impairment; 1 = mild; 2 = moderate; 3 = severe impairment
 
Case Opening*
Case Closing*
Member's Risk to Self
Case Opening*
Case Closing*
Member's Risk to Others
Case Opening*
Case Closing*
Mood Disturbances (depression or mania)
Case Opening*
Case Closing*
Anxiety
Case Opening*
Case Closing*
Thinking / Cognition / Memory / Concentration
Case Opening*
Case Closing*
Impulse / Reckless / Aggressive Behavior
Case Opening*
Case Closing*
Activities of Daily Living Problems
Case Opening*
Case Closing*
Medical / Physical Condition
Case Opening*
Case Closing*
Substance Use / Dependence
Case Opening*
Case Closing*
Job / School Performance
Case Opening*
Case Closing*
Social Functioning / Relationship / Marital / Family
Case Opening*
Case Closing*

Goals

Please enter a Goal
Please enter a Goal
Please enter a Goal
EAP / Psychiatric History Assessed
Please enter Notes
Substance Use Treatment History Assessed
Please enter Notes
Strength, Skills, Aptitude and Interests Assessed
Please enter Notes
Supports Assessed
Please enter Notes
Military History Assessed
Please enter Notes

Case Closing*

Problem Status At Closing:

Case Disposition:

Referral Type:

Substance Use Treatment
Please enter Substance Use Treatment - Other.
Psychiatric Treatment
Please enter Psychiatric Treatment - Other.

EAP Clinician*

Please enter a EAP Clinician Last Name
Please enter a EAP Clinician First Name
Please enter a EAP Clinician Middle Initial
Please enter a Clinician's Mailing Address
Please enter a EAP Clinician City
Please enter a EAP Clinician State
Please enter a EAP Clinician ZIP Code
Please enter a Clinician SSN or Tax ID Number
Please enter a Clinician NPI Number
Please enter a EAP Clinician Phone
Format: xxx-xxx-xxxx
Please enter a EAP Clinician Email

EAP Clinician Signature


PLEASE REVIEW YOUR INFORMATION BEFORE SUBMISSION.

Upon clicking Submit, no changes can be made to this form. You will be provided a confirmation # for your records. If you need a copy of the submission, please print or save this screen prior to clicking submit.

Use Previous button at the bottom of the form to go back and make revisions.

*Required Field


Status Type*
Statement of Understanding Signed*
Release of Information Signed*
 
(corporate client, employer, company/division, location or department through which EAP benefits are available)
Please enter a Payer
Please enter a Participant Last Name
Please enter a Participant First Name
Please enter a Participant Middle Initial
Please enter a Participant Street Address
Please enter a Participant City
Please enter a Participant State
Please enter a Participant ZIP Code
(mm/dd/yyyy)
Please enter a Participant Date of Birth
Please enter a Participant Home Phone
Format: xxx-xxx-xxxx
Participant Relationship to Employee*
 
Relationship Status*
 
Referral Source*
 
Learned About EAP*
Method of Initial Contact*
 
Participant Gender
Please enter a Employee SSN
Note: (if year is unknown, enter 'unknown')
Please enter a Employee Year of Hire
Please enter a Employee Last Name
Please enter a Employee First Name
Please enter a Employee Middle Initial
Employment Status*
 
Job Dysfunction*
 
Job Problem*
 
Job Title Category*
Union Member
 
Session Information: Date(s) of Service (mm/dd/yyyy)*
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
Please enter a Date of Service
*
Please enter Number of EAP Sessions Used at Case Closing

Presenting and Assessed Problem*

choose only one Presenting problem (P) and one Assessed problem (A)
 P      A
Alcohol
Drugs
Mixed Alcohol / Drug Abuse
Anxiety
Depression
Eating Disorder
Hyperactivity/Learning
Impulse Control
Thought Disorder
Child Care
 P      A
Adult / Elder Care
Family Problem
Financial Problem
Grief / Loss
Job / Occupational
Legal
Marital / Relationship
Situational / Adjustment
Medical Problem
Stress

Risk and Functional Assessment*

Indicate participant’s level of impairment at case opening and at case closing.
0 = No evidence of impairment; 1 = mild; 2 = moderate; 3 = severe impairment
 
Case Opening*
Case Closing*
Member's Risk to Self
Case Opening*
Case Closing*
Member's Risk to Others
Case Opening*
Case Closing*
Mood Disturbances (depression or mania)
Case Opening*
Case Closing*
Anxiety
Case Opening*
Case Closing*
Thinking / Cognition / Memory / Concentration
Case Opening*
Case Closing*
Impulse / Reckless / Aggressive Behavior
Case Opening*
Case Closing*
Activities of Daily Living Problems
Case Opening*
Case Closing*
Medical / Physical Condition
Case Opening*
Case Closing*
Substance Use / Dependence
Case Opening*
Case Closing*
Job / School Performance
Case Opening*
Case Closing*
Social Functioning / Relationship / Marital / Family
Case Opening*
Case Closing*

Goals

Please enter a Goal
Please enter a Goal
Please enter a Goal
EAP / Psychiatric History Assessed
Please enter Notes
Substance Use Treatment History Assessed
Please enter Notes
Strength, Skills, Aptitude and Interests Assessed
Please enter Notes
Supports Assessed
Please enter Notes
Military History Assessed
Please enter Notes

Case Closing*

Problem Status At Closing:

Case Disposition:

Referral Type:

Substance Use Treatment
Please enter Substance Use Treatment - Other.
Psychiatric Treatment
Please enter Psychiatric Treatment - Other.

EAP Clinician*

Please enter a EAP Clinician Last Name
Please enter a EAP Clinician First Name
Please enter a EAP Clinician Middle Initial
Please enter a Clinician's Mailing Address
Please enter a EAP Clinician City
Please enter a EAP Clinician State
Please enter a EAP Clinician ZIP Code
Please enter a Clinician SSN or Tax ID Number
Please enter a Clinician NPI Number
Please enter a EAP Clinician Phone
Format: xxx-xxx-xxxx
Please enter a EAP Clinician Email

EAP Clinician Signature