Intake

DOT Return-to-Duty Intake Process

Navigating the DOT Return-to-Duty process can be a daunting task. At SAP Works, LLC, we’re committed to making it as seamless as possible. Our expert team provides personalized guidance and support throughout the entire process, from initial intake to return to work. With our user-friendly online forms and dedicated assistance, you can focus on your recovery while we handle the administrative complexities.

Download and Fill Intake Forms

Download the PDF, fill it out, save it, and upload using the secure form below.

Consent to Treatment Form

Attendence and Cancellation Policy Form

Red Path, Inc.

When you make an appointment with a therapist at our practice, we reserve that time especially for you. We do not overbook our appointments because we feel that our clients deserve to be seen in a timely manner. Just as you deserve your therapist’s full attention during your appointment, we greatly appreciate knowing in advance when a client is unable to keep their appointment. When appointments are cancelled with less than 24 hours notice, it is almost impossible to fill that time slot with another client. Also, please note that insurance companies do not pay benefits for missed and late-cancelled appointments.

Therefore, missed appointments create a financial strain for our practice and make it difficult to serve the many clients on our waiting list. It is also important to note that consistency in attending counseling sessions is critical to effective counseling, and we want our clients to really benefit from our services.

For these reasons, your account will be charged a $60 fee if you miss a scheduled appointment or cancel an appointment with less than 24 hours notice.

Please let our office staff know if there is an extenuating circumstance preventing you from being able to keep your appointment (i.e., illness, death in the family, etc.) as we certainly recognize that unexpected situations can arise.

FINANCIAL POLICY FOR MINOR CHILDREN OF SEPARATED/DIVORCED PARENTS:

It is our policy that the parent who consents to the treatment of a minor child is responsible for payment of the services rendered. Neither Red Path, nor its contracted therapists will be involved with separation/divorce disputes.

By signing below, I acknowledge understanding that Red Path charges a $60 fee for no-shows and appointments cancelled with less than 24 hours notice, and I acknowledge understanding of the client billing policy as it affects treatment of minor children with divorced/separated parents.

Person Served Signature *

Date *

Guardian Signature (if needed)

Date

Consent to Receive Text Messages

Link to FMCSA Intake

CAGE Assessment Form

information

Full Name

Address

Phone

Ethnicity

SS#(last 6)

DOB

- Please Provide the following:

1. Provide 1.10 years of Work History/or send Resume/Education history

2.Please provide your story (why you test positive, who were you with, why was you using this drug, what drug did you tested positive, how often do you use this drug and how much; when was the last time you used this drug, …etc)_You can type on a different paper if you like

- 3.Timeline: Provide dates of hire, date of

a. Date of drug or alcohol use

b. Date of hire

c. Date of Test

- 4.Provide copy of test results- results are located in Clearinghouse. Clearinghouse is for FMCSA *****************************************

5.Are you still working for the company that order the test

Yes No

6.If not are you able to go back to company

Yes No

7.Please circle:

Was the test pre-employment test random test

- 8. Name of Employer’s representative that SAP can talk with concerning your employment history with company

Name of Employer representative

Name of Company

Address

Email address

Phone Number

- 9. Name of Reference who can speak on your behalf; that knows you(family, friend, etc)

PLEASE CONTACT THIS PERSON AS I WILL CALL him or her

Name of Reference

Email address

Phone Number

10.Insurance Information: Do you have insurance?

Name of Insurance Co

Insurance Number

***************************** DON’T forget to Provide copy of test results; results are located in Clearinghouse for FMCSA ************************************

Patient Health Questionnaire (PHQ-9)

Problems	Several days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things	1	2	3
2. Feeling down, depressed, or hopeless	1	2	3
3. Trouble falling or staying asleep, or sleeping too much	1	2	3
4. Feeling tired or having little energy	1	2	3
5. Poor appetite or overeating	1	2	3
6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down	1	2	3
7. Trouble concentrating on things, such as reading or watching television	1	2	3
8. Moving or speaking slowly, or being so fidgety/restless that others noticed	1	2	3
9. Thoughts that you would be better off dead or of hurting yourself	1	2	3

SAP Consent

Full Name

Phone

DOB

Introduction
This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask your SAP any questions you may have regarding its contents. I have chosen to receive SAP services from SAP Works, LLC for myself. My decision is voluntary, and I understand that I may terminate these services at any time.

Compliance with treatment plan
I agree to participate in my treatment plan. I understand that consistent attendance is essential to the success of my treatment. Frequent “no shows” and/or late cancellations may be grounds for termination of services, as well as failure to follow my treatment plan in any form.

Emergencies
If I have a life-threatening emergency situation, I may call 911.

Fees & Insurance
The fee for service is $500.00 for Return to Duty Assessment which consist of Initial evaluation, final evaluation and follow ups. By federal law SAP is unable to take Insurance

Confidentiality
All communications between me and my SAP will be held in strict confidence unless I provide written permission to release information about my treatment. If involved with an EAP, I will sign a consent to release with my EAP.

Client Signature
Your signature indicates that you have read this agreement for services carefully.

Let's Get Started with the DOT Return-to-Duty Process

Get expert guidance and support to ensure a smooth transition back to safety-sensitive functions. Contact us today!

Intake

DOT Return-to-Duty Intake Process

Download and Fill Intake Forms

Consent to Receive Text Messages

Consent to Treatment Form

Attendence and Cancellation Policy

Consent to Treatment Form

Attendence and Cancellation Policy Form

Consent to Receive Text Messages

Link to FMCSA Intake

Assessment

CAGE Assessment Form

Scoring

Psychometric Properties

information

Patient Health Questionnaire (PHQ-9)

SAP Consent

Let's Get Started with the DOT Return-to-Duty Process