Last Updated: July 10, 2023
The purpose of this form is to obtain your consent for Dialogue to provide you with In-Person Employee Assistance Program (EAP) services. This consent is separate from any other consents provided to Dialogue under our other services, found here https://www.dialogue.co/en/consent-form.
By agreeing to this Consent Form, you indicate that you:
Understand and consent to the collection, use and sharing of your personal information including your personal identification, medical, and other personal information, in order to provide you with the In-Person EAP Services offered through Dialogue.
Understand and consent to Dialogue collecting personal information from the independent EAP providers that provide you with the In-Person EAP services for billing and record management purposes.
Understand and consent to Dialogue periodically contacting you by telephone or electronic communication to verify the In-Person EAP services received.
You understand that this consent is valid for the duration of your use of the Services and that you may withdraw it at any time by writing to firstname.lastname@example.org.
You have read and understood this Consent form and you consent to the processing of your personal information, including health information as provided herein.