Life Directions- Counseling in Frederick, MD - EAP Network Provider Requests

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EAP Specific Primary Source Verification

On-Going EAP Network Development

Network EAP Provider and Insurance Matching

Continuous Quality, Continuity of Care

Your satisfaction and our prompt response are our primary goals, thank you for filling out the form below so we can accomplish both.

Employer Name:
Referring EAP Counselors Name:
Requesting EAP Counselors Email:
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Client City:
Client State:
Client Zip Code:
Client Gender:
Concurrent Request:

Type of Interpretor

Interpretor Distance:
Interpretor Fee:
Other Interpretor Specifications:
Insurance Company:
Insurance Website:
Group Number:
Member Number:
Treatment Speciality?:
Language Preference:
Case Urgency Level:

Type Of EAP Case Referral:

EAP Case Number:
Presenting Problem:
Range of Acceptable Fees:
Number of sessions initially authorized:
Providers Contacted or Shouldnt be Considered:
Other Instructions: Any pertinent clinical or case information to be followed or noted:
Distance willing to travel:

Provider Gender Preference:

Request Date & Time:
Requestors Time Zone:

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Experience With:

Life Change and Transition
Deployment
Re-intergration of Civilian and Service Families
Occupational Trauma
Depression
Anxiety
Self Injury
Anger Management
Threats of Violence
Domestic Violence
Workplace Violence
Obessive Complusive Disorder
Attention Deficit Disorder
Attention Deficit Hyperactivity Disorder
Bi-Polar Disorder
Pre-Marital Counseling
Partnership Counseling
Gay & Lesbian Issues
Transgender Issues
Trust/Communication
Couples Counseling
Infertility
Adoption
Parenting
Death of Child
Grief and Loss
Trauma Reprocessing
Career Evaluation or Re-Evaluation
Spirituality Exploration, Guidance,& Development
Body Dysmorphic Disorder
General Medical Conditions exacerbating Mental Health Issues