LEFT Wellness Consultation Referral & Consent Form

KESMA Flame Lily LLC Law Enforcement and First Responder Program partners with multiple law enforcement and first responder agencies to provide annual wellness consultations/check-ins. This service is funded by the department/agency and is meant to encourage employees to do more for themselves and feel supported in doing so.

Please complete the following consent form to get your appointment scheduled. If we have availability during one of the times you listed, you will receive an e-mail invite for your appointment. If we do not have availability, a member of the Law Enforcement and First Responder team will reach out to you by phone to find another time that works for you. If you have any questions while scheduling your appointment, please call or text 651-319-1059.

Name

Date of Birth

Phone Number

Email Address

Department/Agency

Would you prefer meeting In-Person or via Telehealth? *In-Person onlyTelehealth onlyEither one

Which office location(s) do you prefer for In-Person meetings?

Saint PaulMendota Hts

Name of specific provider you'd like to see or male/female preference: *

Please list 3-4 upcoming dates & times that you are available for a 50-60 minute Wellness Consultation. If you work overnights, please give your availability at the beginning or end of your shift. ***Your Wellness Consultation will be scheduled within one of these time frames & confirmation will be emailed to you. If there are no available appointments during the above dates & times, you will receive a phone call from Ellie Mental Health staff to find another time that works for you.

Before engaging in a Wellness Consultation at KESMA Flame Lily, it is important for you to understand the following information. Wellness Consultations are part of a wellness initiative offered by your employer. Your employer will NOT be notified of any personal information shared or the topics of interest indicated by you during your Wellness Consultation. The only information your employer will receive is your name, date of appointment, and whether you attended the appointment.

Wellness Consultations are not mental healthcare services: There is no formal assessment or evaluation of your mental health needs. You will not receive a diagnosis for a mental health disorder. Engagement in a Wellness Consultation will not be documented in your medical record. You will not be engaging in medically necessary or therapeutic services, and no part of your Wellness Consultation will be considered treatment of any medical or mental health disorder. Rather, Wellness Consultations are an opportunity for you to work with a knowledgeable professional who will provide best practices for promoting overall emotional and mental wellness. You will identify the areas of life in which the consultation will focus upon. If you think you may benefit from traditional mental health therapy instead of a Wellness Consultation, Ellie Mental Health will help you identify what those therapy services might be and make referrals for further support, at your request. You are not limited to receiving only one type of service. For instance, you could sign up for Wellness Consultations now and decide to seek out mental health therapy later, or vice versa. We just want to make it clear that Wellness Consultations are not mental health therapy services. Additionally, we make no promises that engaging in Wellness Consultations will change your behavior, circumstances, or that a specific outcome will happen.

By signing this form below, I agree that I understand the preceding information outlined regarding engaging in a Wellness Consultation at Ellie Mental Health.

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Date

Law Enforcement + First Responder Wellness Consultation Form

LEFT Wellness Consultation Referral & Consent Form

Which office location(s) do you prefer for In-Person meetings?