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VBI Affiliate Billing Submissions Form
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* Indicates required question
Email
*
Your email
Authorization Number
*
Your answer
Counselors Name
*
Your answer
Make check payable to
*
Your answer
Mailing Address/City/State/Zip
*
Your answer
Federal Tax ID
*
Your answer
Service being provided
*
Mental Health
CD Evaluation
SAP Evaluation
Education Group
Other:
Presenting Concern
*
Academic Performance
Truancy/Behavior Problems
Educational Other
Abuse/Neglect
Anger
Depression/Anxiety
Eating Disorder
Grief/Loss
Personal Adjustment
Self-Concept/Esteem
Emotional Stress
Suicidal/Homicidal Ideation
Job Stress
Emotional Other
Divorce/Separation
Family Conflicts
Parenting
Primary Relationship Issues
Relationships Other
Co-worker issues
Employee/Supervisor Conflicts
Work Other
Alcohol/Drugs, non-household
Alcohol/Drugs, household
Alcohol/Drugs, self
SAP Evaluation
Date of Session
*
MM
/
DD
/
YYYY
Date of Session
MM
/
DD
/
YYYY
Date of Session
MM
/
DD
/
YYYY
Date of Session
MM
/
DD
/
YYYY
File Status
*
File Closed
Services Continuing
Did you review The Village Acknowledgement Statement with the Village EAP Client at first session?
*
Yes
No
Additional Information and/or Formal Referral Recommendations
Your answer
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