Confidential Document
Closing Summary
Referring FSEAP File No.: / Referring FSEAP Office:Internal File #:
Client Initials: / Counsellor/Affiliate Name:
Section I: Closing Notes
Overall Primary Case Problem Addressed (one only):Overall Secondary Case Problem Addressed (one only):
Closing Date (MM / DD / YYYY): / Total Hours of Service Provided (by counsellor):
Case Disposition: (Please describe progress towards client goals, achieved outcomes and recommendations for unresolved issues).
Service SMART Goals/Objectives: / Outcome:
1. / Achieved Partially Achieved Not Achieved
2.
/ Achieved Partially Achieved Not Achieved
Recommendations for unresolved issues:
Made client aware they can access service at anytime by calling their FSEAP provider.
Referred client to external provider or community resource
Referral Accepted by Client
Client made successful connection with referred source. / Name of referral source:
Client follow-up completed. Date of follow-up contact with client:
Resolution: (Please check only one)
EAP counselling case only – no referral to community resource
EAP case and referral to community resource
EAP and Work/Life
Work/Life only / Closing Recommendation: (please check only one)
No recommendation
Referral to a community resource
Recommend additional sessions – longer term counselling
Recommend healthier lifestyle choices
Referral for medical assessment
Referral for a mental health assessment
Referral to a spiritual resource
Recommendation to read literature
Notes: (Please provide summary statement regarding service / closing).
Counsellor Signature:
Case Problems:
Addiction
- Alcohol
- Drug
- Gambling
- Internet
- Sexual
- Other / Trauma
- Assault/Robbery
- Childhood Abuse
- Domestic Violence
- Other Traumatic Event
- Workplace Accident
o / Relationship (Family)
- Blended Family
- Childcare
- Eldercare
- Extended Family
- Marital/Partnership Concerns
- Parent/Child
- Separation/Divorce
- Sexual Issues
- Other / Personal (Psychological)
- Anger
- Anxiety
- Depression
- Developmental Transitions
- Grief/Loss
- Financial
- Legal
- Medical/Health
- Nutrition
- Orientation/Gender Identify
- Psychiatric Issues
- Self Esteem
- Stress / Work
- Conflict
- Career
- Disability/Return to Work
- Morale
- Organizational Change
- Performance Issues
- Stress
- Work/Life Balance
- Unemployment
- Workload
- Other
- Please retain original on client file, submit copy with FSEAP billing -
FSEAP Version/Jul2011 Closing Summary