DEPARTMENT OF PUBLIC WORKS CONSENT FORM TO DISCLOSE INFORMATION
CONFIDENTIAL EAP This form notifies the Department about employee consultation with EAP
I ___________________________________________, authorize __________________________ to notify and inform Department /employer of my consultation with EAP to provide Department with periodic updates of my progress if necessary. The EAP component can disclose my consultation, progress, nature of my problem and course of treatment to the department. I have been informed of the risks and benefits of releasing this information. The EAP services are dependent upon my decision concerning the releasing of this information. I understand that this consent is subject to revocation at any time. However, revocation has no effect on effect disclosure made before EAP receive written revocation. I have read and understand this form, and sign name hereunder freely, voluntary and without coercion* *This form must be signed by a competent adult and mentally stable employee.
Name of employee (please print) ______________________________________________________ Signature Date
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Address of employee
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Name of the section /Component ________________________________________________________ Persal Number
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Name of witness (person who can attest to the identity of the person signing this form) _______________________________________________________________________________________ Signature of witness and Date _______________________________________________________________
Witness Tel No. and Address_______________________________________________________________
