Intake Form to Access Services

Employee/Member's Information
Employer/Membership
Employee/Member Name*
First Last
Relationship to Employee/Member*
Years With Employer/Member
Requester's Information
Name (If you are not the employee)
First Last
Date of Birth*
Address*
Street Address City State Zip Code
Phone Number*
Type of Contact Phone Number*
Is it OK to leave a message at this number?
Email (Used only for communication purposes)*
May we send you a satisfaction survey to your email?
Satisfaction surveys are sent out 3 months after initial contact with EAP.
What reason has led you to contact us?*
How did you hear about the Employee Assistance Program?
Briefly describe how we can assist you
Name
This field is for validation purposes and should be left unchanged.

Employee/Member's Information