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</div></div><hr><p><strong><span style=\'font-size: 24px;\'>Minors</span></strong></p><p>If the patient is a minor, please complete the additional information below.</p><hr><div class=\'form-group\'><label for=\'FormField14_56ec55aa-694a-462e-bafa-1fc451deeb48\' class=\'control-label  \'>Parent/Guardian Name</label><div>\
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</div></div><hr><p><strong><span style=\'font-size: 24px;\'>Employee Assistance Program Statement of Understanding</span></strong></p><p><strong>Mercy EAP Services, L.L.C.</strong> offers assessment, short-term counseling, referral and follow-up services to employees and immediate family members of contracted companies. EAP services are provided at <strong>NO COST</strong> to you. &nbsp;<br><br>In some cases, referrals to service providers outside of the EAP may be recommended. You decide whether to follow the EAP clinician&rsquo;s recommendations. Any cost for services outside of the EAP are your responsibility. &nbsp; &nbsp;<br><br><strong>Confidentiality:&nbsp;</strong>EAP services are strictly confidential within the limits of the law. No one will reveal information concerning your counseling to anyone outside the program except as follows:<br><br>(1) &nbsp; &nbsp;you consent in writing; &nbsp;<br>(2) &nbsp; &nbsp;there is a threat of harm to oneself or others;<br>(3) &nbsp; &nbsp;there is suspected or reported child or dependent adult abuse;<br>(4) &nbsp; &nbsp;to meet the requirements of a court subpoena;<br><br><strong>Supervisory/Company Referrals:&nbsp;</strong>If you have been referred to the program due to work-related problems, the EAP clinician will advise the referral source whether you keep the initial appointment and agree to treatment recommendations. No other information will be released unless written authorization is provided except as required by law. &nbsp; &nbsp;<br><br>I have read and understand the content of this statement:</p><div class=\'form-group\'><label for=\'FormField21_56ec55aa-694a-462e-bafa-1fc451deeb48\' class=\'control-label  \'>Signature<span class=\'fb-required\'>*</span></label><div>\
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