EAP (Humanitarian Support Services) Form

EAP AUTHORIZATION FORM

The Humanitarian understands that policies and protocols guiding how data is transmitted and temporarily stored via this form and on this platform (Snapforms) is based on ISO27001, the Australian Government Information Security Manual, ACSC cyber security principles and guidelines including the Essential Eight Model, the Australian Privacy Principles and Privacy Act.

Authorizer's details

Organization requesting service *

FIRST NAME of authorizer *

SURNAME of authorizer *

Authorizer's role in the organization *

Email address of authorizer *

Telephone contact of authorizer *

Staff member or Delegate or Volunteer details

By providing this information, you are acknowledging that you have authorisation to convey personal details on behalf of a staff member, delegate or volunteer.

FIRST NAME of staff member requiring a psychological consultation *

SURNAME of staff member requiring a psychological consultation *

Role of staff member within the organization *

Email address of staff member *

Mobile number of staff member *

Nationality of staff member? *

Location of staff member? (Include country) *

Likely time difference (compared to AEST) *

Service

When does the staff member/ delegate/ volunteer deploy? *

When did the staff member/ volunteer/ delegate deploy? *

When does the staff member/ delegate/ volunteer return from deployment? *

Other notes relevant to type, logistics or timing of this appointment request? *

Background information

Information Disclosure: Please note that information disclosed on this form will be discussed openly with the staff member/ delegate / volunteer at the outset of the session.

Please ensure you are authorised to disclose personal or sensitive information.

What is the desired outcome of the consultation? *

Any specific background / incidents/ risk factors /vulnerabilities of staff member/ delegate / volunteer that psychologist should be made aware of prior to the session? *

How experienced in humanitarian missions/ overseas deployments is the staff member / delegate / volunteer? *

Outline any special needs, mobility or language requirements of the consultation *

Are there any Workcover, TAC, NDIS, DVA, legalities, court or other third party associations with this request? *

NoYes

Please outline *

Feedback

Is any feedback required to the organisation? *

No - the sessions are completely confidentialYes (please note that this request will be discussed with the staff member / delegate / volunteer prior to the first session commencing and consent to disclosed will need to be gained before sharing information with the staff member's employer).

To whom should feedback be shared? *

Email address to whom feedback is to be sent *

Nature of feedback required *

When does this request/authorisation expire? *

Any other comments? *

Form copy

Do you require a PDF copy of this completed form? *

YesNo

Email address for conveying PDF copy of this form *

Your nominated password for protecting the privacy of the form (4 digits) *

Invoicing details

The current recommended cost of service by the Australian Psychological Society is $300 per hour.

Your organization will be billed at the agreed rate of $210 per hour.

Purchase order reference to appear on the invoice (for confidentiality reasons, do not use the staff member's name) *

Invoice to be directed to

Name *

Role title *

Department: *

Organisation *

Invoicing postal address *

Invoicing email address *

Invoicing email address (2)

Authorizer's signature & date

Signature *

Draw signature|Type signatureClear

Date *