Get Please Retain For Your Records - Empathia

Filling out the Please Retain For Your Records - Empathia form is a critical step for users continuing therapy after their Employee Assistance Program (EAP) services have been completed. This guide provides clear and detailed instructions to help you complete the form correctly and efficiently.

Follow the steps to fill out the form accurately.

1. To begin, locate and press the ‘Get Form’ button to access the document. This will enable you to open the form in an editable format.
2. In the first section, fill in your name where it states 'I, _______________________________'. This verifies that you have been offered a referral to additional counseling resources.
3. Confirm your decision by stating that you choose to seek ongoing assistance through your EAP provider's private psychotherapy or clinic practice. This section helps document your choice.
4. Next, sign and date the space labeled 'Client Signature' and 'Date' to indicate your agreement to the terms. Ensure your signature matches the one on your identification documents.
5. A clinician or witness must also sign in the section provided for 'Clinician Signature/Witness' and date the form as well. This step validates the agreement.
6. You are required to list two alternative treatment providers in the designated area. Each provider should be inquiring relevant details including their name and phone number.
7. Finally, review all the information entered to ensure accuracy. Once confirmed, save your changes. You may also choose to download, print, or share a copy of the completed form for your records.

Complete your documents online today for a seamless and efficient process.