/ Carelon Behavioral Health On-Site EAP Case Activity Form Carelon Behavioral Health On-Site EAP Case Activity Form 1 Enter Information 2 Review Details 3 Submit (Use only if EAP services delivered by 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* Interim Final Statement of Understanding Signed* Yes No Release of Information Signed* Yes No Payer* (corporate client, employer, company/division, location or department through which EAP benefits are available) Please enter a Payer Participant Information: Last Name* Please enter a Participant Last Name First Name* Please enter a Participant First Name MI Please enter a Participant Middle Initial Participant's Address: Street Address* Please enter a Participant Street Address City* Please enter a Participant City State* Please enter a Participant State ZIP Code* Please enter a Participant ZIP Code Date of Birth* (mm/dd/yyyy) Please enter a Participant Date of Birth Participant Relationship to Employee* Self Spouse Dependent Parent Sibling Unmarried Partner Other Relationship Status* Never Married Married Separated Divorced Widowed Cohabitating Data Not Provided Referral Source* Self Union Co-worker Medical HR Supervisor (Informal) Wellness Program Treatment Provider Supervisor (Job Performance) Data Not Provided Learned About EAP* Word of Mouth Printed Materials Company Representative Electronic Media Training / Health Fair Union Representative Participant Had Previous Contact With EAP Data Not Provided Method of Initial Contact* On-Site EAP Participant Gender Female Male Other/undisclosed/unknown Employee Year of Hire Note: (if year is unknown, enter 'unknown') Please enter a Employee Year of Hire Employee Name: (if not participant) Last Name Please enter a Employee Last Name First Name Please enter a Employee First Name MI Please enter a Employee Middle Initial Employment Status* Full Time Part Time Terminated Medical Leave Retired Disciplinary Leave Laid Off Disability / Worker's Compensation Leave Other Data Not Provided Job Dysfunction* None Minimal Moderate Significant: No Job Jeopardy Significant: Job Jeopardy Data Not Provided Job Problem* None Absenteeism Fitness for Duty Safety Issue(s) Unpaid Leave Tardiness Positive Drug Screen Employee Tested Positive for Alcohol Productivity Issue(s) Co-worker Relationship Supervisor Relationship Aberrant Behavior Work Performance Job Title Category* Executive / Manager Professional Sales Office / Clerical Service Worker Technical Craft Worker (skilled) Operative (semi-skilled) Laborer (unskilled) Data Not Provided Union Member Yes No 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 Number of EAP Sessions Used at Case Closing* 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* 0 1 2 3 Case Closing* 0 1 2 3 Member's Risk to Others Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Mood Disturbances (depression or mania) Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Anxiety Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Thinking / Cognition / Memory / Concentration Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Impulse / Reckless / Aggressive Behavior Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Activities of Daily Living Problems Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Medical / Physical Condition Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Substance Use / Dependence Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Job / School Performance Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Social Functioning / Relationship / Marital / Family Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Goals 1. Please enter a Goal Met Partially Met Not Met No Change 2. Please enter a Goal Met Partially Met Not Met No Change 3. Please enter a Goal Met Partially Met Not Met No Change EAP / Psychiatric History Assessed Yes No Notes Please enter Notes Substance Use Treatment History Assessed Yes No Notes Please enter Notes Strength, Skills, Aptitude and Interests Assessed Yes No Notes Please enter Notes Supports Assessed Yes No Notes Please enter Notes Military History Assessed Yes No Notes Please enter Notes Case Closing* Problem Status At Closing: Resolved Partially Resolved Getting Worse No Change Not Applicable Case Disposition: Face-to-Face Assessment / No Referral Face-to-Face Assessment / Referral Accepted Face-to-Face Assessment / Referral Declined Video Assessment / No Referral Video Assessment / Referral Accepted Video Assessment / Referral Declined Telephone Assessment / No Referral Telephone Assessment / Referral Accepted Telephone Assessment / Referral Declined Did Not Keep Initial Appointment Withdrew Before Completion of Services Referral Type: No Referral Beyond EAP Community Resource Medical Treatment Substance Use Treatment Inpatient Intensive Outpatient Detox Only Other Other Please enter Substance Use Treatment - Other. Psychiatric Treatment Inpatient Partial Hospitalization Outpatient (non-MD) Outpatient (MD) Other Other Please enter Psychiatric Treatment - Other. EAP Clinician* EAP Clinician: Last Name* Please enter a EAP Clinician Last Name First Name* Please enter a EAP Clinician First Name MI Please enter a EAP Clinician Middle Initial Clinician's Mailing Address: Street Address Please enter a Clinician's Mailing Address City Please enter a EAP Clinician City State* Please enter a EAP Clinician State ZIP Code Please enter a EAP Clinician ZIP Code Tax ID Number Please enter a Clinician Tax ID Number NPI Number* Please enter a Clinician NPI Number Clinician Phone Please enter a EAP Clinician Phone Format: xxx-xxx-xxxx Clinician Email Please enter a EAP Clinician Email EAP Clinician Signature By checking the box you are certifying the accuracy of all information contained in this form.* 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* Interim Final Statement of Understanding Signed* Yes No Release of Information Signed* Yes No Payer* (corporate client, employer, company/division, location or department through which EAP benefits are available) Please enter a Payer Participant Information: Last Name* Please enter a Participant Last Name First Name* Please enter a Participant First Name MI Please enter a Participant Middle Initial Participant's Address: Street Address* Please enter a Participant Street Address City* Please enter a Participant City State* Please enter a Participant State ZIP Code* Please enter a Participant ZIP Code Date of Birth* (mm/dd/yyyy) Please enter a Participant Date of Birth Participant Relationship to Employee* Self Spouse Dependent Parent Sibling Unmarried Partner Other Relationship Status* Never Married Married Separated Divorced Widowed Cohabitating Data Not Provided Referral Source* Self Union Co-worker Medical HR Supervisor (Informal) Wellness Program Treatment Provider Supervisor (Job Performance) Data Not Provided Learned About EAP* Word of Mouth Printed Materials Company Representative Electronic Media Training / Health Fair Union Representative Participant Had Previous Contact With EAP Data Not Provided Method of Initial Contact* On-Site EAP Participant Gender Female Male Other/undisclosed/unknown Employee Year of Hire Note: (if year is unknown, enter 'unknown') Please enter a Employee Year of Hire Employee Name: (if not participant) Last Name Please enter a Employee Last Name First Name Please enter a Employee First Name MI Please enter a Employee Middle Initial Employment Status* Full Time Part Time Terminated Medical Leave Retired Disciplinary Leave Laid Off Disability / Worker's Compensation Leave Other Data Not Provided Job Dysfunction* None Minimal Moderate Significant: No Job Jeopardy Significant: Job Jeopardy Data Not Provided Job Problem* None Absenteeism Fitness for Duty Safety Issue(s) Unpaid Leave Tardiness Positive Drug Screen Employee Tested Positive for Alcohol Productivity Issue(s) Co-worker Relationship Supervisor Relationship Aberrant Behavior Work Performance Job Title Category* Executive / Manager Professional Sales Office / Clerical Service Worker Technical Craft Worker (skilled) Operative (semi-skilled) Laborer (unskilled) Data Not Provided Union Member Yes No 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 Number of EAP Sessions Used at Case Closing* 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* 0 1 2 3 Case Closing* 0 1 2 3 Member's Risk to Others Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Mood Disturbances (depression or mania) Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Anxiety Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Thinking / Cognition / Memory / Concentration Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Impulse / Reckless / Aggressive Behavior Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Activities of Daily Living Problems Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Medical / Physical Condition Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Substance Use / Dependence Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Job / School Performance Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Social Functioning / Relationship / Marital / Family Case Opening* 0 1 2 3 Case Closing* 0 1 2 3 Goals 1. Please enter a Goal Met Partially Met Not Met No Change 2. Please enter a Goal Met Partially Met Not Met No Change 3. Please enter a Goal Met Partially Met Not Met No Change EAP / Psychiatric History Assessed Yes No Notes Please enter Notes Substance Use Treatment History Assessed Yes No Notes Please enter Notes Strength, Skills, Aptitude and Interests Assessed Yes No Notes Please enter Notes Supports Assessed Yes No Notes Please enter Notes Military History Assessed Yes No Notes Please enter Notes Case Closing* Problem Status At Closing: Resolved Partially Resolved Getting Worse No Change Not Applicable Case Disposition: Face-to-Face Assessment / No Referral Face-to-Face Assessment / Referral Accepted Face-to-Face Assessment / Referral Declined Video Assessment / No Referral Video Assessment / Referral Accepted Video Assessment / Referral Declined Telephone Assessment / No Referral Telephone Assessment / Referral Accepted Telephone Assessment / Referral Declined Did Not Keep Initial Appointment Withdrew Before Completion of Services Referral Type: No Referral Beyond EAP Community Resource Medical Treatment Substance Use Treatment Inpatient Intensive Outpatient Detox Only Other Other Please enter Substance Use Treatment - Other. Psychiatric Treatment Inpatient Partial Hospitalization Outpatient (non-MD) Outpatient (MD) Other Other Please enter Psychiatric Treatment - Other. EAP Clinician* EAP Clinician: Last Name* Please enter a EAP Clinician Last Name First Name* Please enter a EAP Clinician First Name MI Please enter a EAP Clinician Middle Initial Clinician's Mailing Address: Street Address Please enter a Clinician's Mailing Address City Please enter a EAP Clinician City State* Please enter a EAP Clinician State ZIP Code Please enter a EAP Clinician ZIP Code Tax ID Number Please enter a Clinician Tax ID Number NPI Number* Please enter a Clinician NPI Number Clinician Phone Please enter a EAP Clinician Phone Format: xxx-xxx-xxxx Clinician Email Please enter a EAP Clinician Email EAP Clinician Signature By checking the box you are certifying the accuracy of all information contained in this form.* Please complete the reCAPTCHA challenge field above. Your form was successfully submitted. 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