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First Name*

Last Name*

How can we help you?

User Name

Employee ID

Date of Birth*

Address

City

State

Zip Code

Best way to contact you to set up an appointment?*

If phone, provide a number where we can leave a message

Phone Type

If email, see below

Appointment Availability

We will contact you within 1 business day to schedule an appointment. Typically, we schedule appointments within 3-5 business days from date of contact. If your matter is urgent, please call 866-724-4327. Please check all options that apply.

Your preferred appointment days?

Monday

Tuesday

Wednesday

Thursday

Friday (no 5PM appointments)

Your preferred appointment times?

8AM – 11AM

11AM – 3PM

3PM – 5PM

Your preferred appointment locations?

by Telephone

by Video

Additional information that will assist us in scheduling an appointment for you

Mass General Brigham Assistance Program Consent to Services

The Mass General Brigham Assistance Program, herein after in this agreement shall be named the “Program”. Program services may include assessment, brief problem solving and referral. The Program Counselor will work with you to clarify the issues, identify choices, and develop an action plan. Use of the Program is voluntary.

Participation in the Program does not in any way affect an employee’s job security, promotional opportunities, corrective or disciplinary action, or other employment rights.
Our goal is to be respectful and responsive to cultural and linguistic differences. We are committed to making communication accessible to all people creating a welcoming environment for all. Interpretive services including American Sign Language are available. Please indicate if you need assistance.
Our services are provided by trained, licensed professionals with master’s degrees in counseling, psychology or social work, as well as graduate interns in these fields.

Fees: These services are provided at no cost to eligible employees and your immediate household members (this does not include roommates), while you are employed.

The Program may assist you in locating a resource in your community. It is your responsibility to pay for services provided by resources outside the Program. If you need counseling, the Program will try to match you with a provider that is covered by your insurance plan, but it is your responsibility to determine whether such services are covered by your insurance.
The Program is not liable for resources provided outside of the Program..
Once it is agreed upon that your Program services are completed, we will follow-up with you to ask if your service goals were achieved, and at that time your case will be closed. You are welcome to return for services in the future.

Confidentiality: The Program will maintain the confidentiality of your contact with the Program and your Program records, which include the dates and types of services provided to you. Your Program records are kept in secured computer files and in our locked offices. They are not part of the medical record system, personnel files or insurance company records. Emails you send to the program will become part of your Program record. Information about your use of the Program will not be revealed to anyone outside the program except as follows:

If we receive your consent in writing;
In case of suspected elder, child, disabled and/or nursing home patient abuse or neglect;
If the Program determines there is a serious threat to life or safety of self or others, or to the workplace, including patients;
The disclosure is required by a court order;
If, in our judgment, there is a serious medical emergency which requires immediate medical attention;
6. As required by the Program for independent audit and program evaluation.

Complaints Concerning Harassment and/or Discrimination: The Program is confidential; discussions with the Program counselor regarding concerns of workplace harassment, violation of organization policy or discrimination are not considered official notification to your employer. We recommend that you follow your organization’s policy regarding the reporting of such incidents.

Office Hours and After Hours: Office hours are Monday - Friday, 8:00 a.m. to 5:00 p.m. Evening and early morning appointments are available upon request. If you have an emergency when the office is closed, call 866-724-4327 and follow instructions to page the Program After Hours On-Call Counselor or call 911 and go to your local emergency room.

Your Rights:

The Program complies with applicable Federal civil rights laws and does not discriminate, exclude people or treat them differently based on race, color, national origin, age, disability, gender or sexual orientation.
You may request a copy of your record, but your request may not be granted if we believe access to your record would cause you harm. You have the right to end Program services at any time. We encourage you to speak directly with your counselor if you have concerns or a complaint about any aspect of the Program service. You can also contact the Program Director or Senior Clinical Manager to register your concerns.
We retain the right to terminate services if we believe you pose a safety risk to our staff; our policy is available upon request.

Informed Consent to use of Email

May we contact you by email?*

If you prefer not to authorize the use of email, we will continue to use U.S. Mail, fax or the telephone to communicate with you.

By indicating “yes” on this form, I authorize the Program to communicate with me via email. The most secure ways for us to communicate with you via email are to stay within the Mass General Brigham firewall using your Mass General Brigham/Partners email or send you an email on your personal account that is encrypted by “send secure”.

If “yes”, please provide your email address

How do you prefer to receive your email?*

By signing the bottom of this form, I understand the use of unsecure/unencrypted email has some risk of interception (being read by others) and I understand these risks.

Submit

Information regarding the Program Telehealth Appointment

I understand that if I choose to access the Program using a telehealth visit, I am authorizing information about myself to be electronically transmitted in the form of images, voice and data through an interactive electronic connection to and from the Program.

I understand that a telehealth visit involves the use of electronic (computer) technology and an electronic network. All transmissions are encrypted. The Program does not record these sessions; I agree not to record these sessions either. While these efforts provide strong protections to preserve the security and confidentiality of these transmissions, I understand that no system is 100% secure and I accept the risk that such transmissions may, but will likely not, become viewable by third parties intercepting such transmission.
I understand that it is my responsibility to ensure that the transmission is not viewed or overheard by third parties with access the device that I am using to receive this transmission.
I understand the electronic connection may be interrupted during a telehealth visit due to an unavoidable breakdown in technology. If a technology interruption occurs, both parties will try to reconnect. If the connection cannot be made within ten minutes, I understand I can call 866-724-4327 to continue the session via telephone or to reschedule the telehealth appointment.
I can decide to stop using telehealth visits at any time and elect to be seen in person or be served by other means available from the Program. Also, the Program counselor may decide to stop the telehealth visit if it appears to be detrimental to the service. If circumstances require an urgent or emergency response, Program staff will be prepared to direct me to the appropriate level of care. The Program’s response may include directing me to a local emergency service, hospital or nearby Program office for an in-person assessment to create a plan to maintain safety.

Program Privacy Notice

Federal law requires that all clients be given a copy of the Program Privacy Notice. The Privacy Notice describes in detail how “protected health information” is used and shared with others. The Program has reserved the right to change the Privacy Notice at any time. Obtain a current copy of the Program Privacy Notice or by contacting the main Program office at 866-724-4327. All reasonable efforts will be made to protect the privacy of Program clients’ protected health information, whether it is maintained on paper or electronically, and regardless of how it is communicated, for example, by email or facsimile.

I understand this Statement, including the confidentiality of the Program and the limitations to confidentiality, and accept it as the terms of my participation in the Program including telehealth visits.

By signing these agreements, (use of email, confidentiality and telehealth) I acknowledge that I have read, understand this statement, including the limitations to confidentiality. I agree to the terms above and I acknowledge that my typed or electronic signature is as legally binding as an original signature.

Consent Full Name*

Sign Here Using Mouse or Finger/Stylus Use Keyboard

Online Request Form for Mass General Brigham Assistance Program Services for Employees

This form is for setting up non-urgent appointments only.

If you are experiencing a life-threatening situation, or if you are experiencing suicidal thoughts, homicidal thoughts or domestic violence, DO NOT complete this form. Please call 911 or go to the nearest emergency room.

Informed Consent to use of Email

Information regarding the Program Telehealth Appointment

Program Privacy Notice